I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
Naomi
Middle Name: (optional)
Last Name:
Kansaki
Gender: (select one)- [] Male
- [X] Female
05/JAN/2002
Address:
3 Lindsay Circus, Little Seoul
ZIP / Postal Code:
90016
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
16991064
Email:
[email protected] (( Twennyone ))
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [] Yes
- [X] No
- [] Yes
- [X] No
ANSWER (N/A if the answer to the previous question is 'No')
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
I have serious psychological problems, due to a certain incident.
After this happened, I was referred by a friend to Doctor Sade Aliz,
who in turn referred me online to the "Request an appointment" website.
Is this condition or injury related to work?- [] Yes
- [X] No
- [] Yes
- [X] No
- [] Medical
- [X] Psychology
- [X] 25/JUN/2022 - 20:00 : 03:00
[X] 26/JUN/2022 - 16:00 : 03:00
[X] 27/JUN/2022 - 16:00 : 03:00
[] 28/JUN/2022 - 16:00 : 03:00
[] 29/JUN/2022 - 16:00 : 03:00
[] 30/JUN/2022 - 16:00 : 03:00
[] 01/JUL/2022 - 16:00 : 03:00
Sade Aliz, Psy.D.