I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
Camila
Middle Name: (optional)
Adella Perez
Last Name:
Elizondo
Gender: (select one)- [] Male
- [X] Female
18/OCT/1995
Address:
1170 Cougar Ave - Floor 4, Room 1, Morningwood, Los Santos, San Andreas
ZIP / Postal Code:
10910
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
3170
Email:
[email protected] (( OZONE ))
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [X] Yes
- [] No
- [] Yes
- [X] No
N/A (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.)
Trying to recover from a traumatic event that occurred a few weeks prior. Mainly need help with coping mechanisms and tips on moving on from what happen to me. Despite my best attempts, I am still having anxiety, nightmares, and insomnia and I decided that I need to see professional help.
Is this condition or injury related to work?- [] Yes
- [X] No
- [] Yes
- [X] No
- [] Medical
- [X] Psychology
- [] 25/JUN/2022 - 15:00
[X] 26/JUN/2022 - 15:00
[] 02/JUL/2022 - 15:00
[] 03/JUL/2022 - 15:00
[] 16/JUL/2022 - 15:00
[] 17/JUL/2022 - 15:00
[] 30/JUL/2022 - 15:00
/list]
Preferred Doctor for Appointment: (check the list of doctors here and pick one based on personal preference. Note that this is optional and if you don't choose one, one will be automatically assigned to you.)
Any are fine with me.