The Lisa McPherson Files

HOSPITAL ROUTINE INQUIRY FOR ORGAN DONATION

A. PATIENT'S NAME McPherson, Lisa ?

CHART NO 37128606

PATIENT'S AGE: ?

SEX: F

DATE OF DEATH: 12-5/95

ETHNICITY: BLACK ___ HISPANIC ___ AMERICAN INDIAN ___ WHITE _X_ ASIAN ___ OTHER ___

B. NAME OF NEXT OF KIN: ?

2. LIFELINK CALLED: 1-800-XXX-XXXX) W/TIME: 2350 12/5/95

3. REQUESTOR'S NAME AND TITLE: Margo

A. PATIENT MEDICALLY SUITABLE TO BE CONSIDERED AS A POTENTIAL DONOR:

YES: ___ NO: _X_ IF NO, REASON: ME Case

B. REQUEST MADE: YES: ___ NO: _X_ IF NO, REASON: ME Case

C. IF YES, WAS CONSENT GIVEN: YES ___ NO ___

IF CONSENT NOT GIVEN, REASON:

CONTACT W/NEXT OF KIN:

___ ATTEMPTED, COULD NOT BE FOUND.

___ REFUSED CONSENT FOR DONATION

D. MEDICAL EXAMINER'S RELEASE REQUIRED: YES _X_ NO ___

MEDICAL EXAMINER'S OFFICE CONTACTED: YES _X_ NO ___

DATE & TIME OF CONTACT: 12/5/95 2350

NAME OF PERSON SPOKE WITH: Debbie

MEDICAL EXAMINER'S RELEASE OBTAINED: YES ___ NO _X_
MEDICAL EXAMINER'S AUTHORIZING RELEASE: __________

E. ORGANS OR TISSUES DONATED:

ORGANS OBTAINED: YES ___ NO _X_

TISSUES OBTAINED: YES ___ NO _X_

REQUESTOR'S SIGNATURE [signature] DATE: 12/5/95

COPIES: WHITE: MEDICAL RECORDS/YELLOW:

PROCUREMENT/PINK: ADMINISTRATION

ON COMPLETION DO NOT SEPARATE FORM**

COLUMBIA NEW PORT RICHEY HOSPITAL/NURSING DEPARTMENT CH333