I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
Tiffany
Middle Name:
Stacie
Last Name:
Sims
Gender: (select one)- [] Male
- X[] Female
20/04/2004
Address:
1068 San Andreas Avenue - Floor 4, Room 4
ZIP / Postal Code:
48204
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
9381-310
Email:
[email protected](( strawberry ))
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [X] Yes
- [] No
- [X] Yes
- [X] No
(( Got diagnosed schizphrenic but was told to make an appointment to get a formal/legit report ))
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
Seeing and hearing things that aren't there, it's only getting worse.
Is this condition or injury related to work?- [] Yes
- [X] No
- [] Yes
- X[] No
- [] Medical
- [X] Psychology
- [X] 15/09/2022- 21:00
[X] 16/09/2022- 21:00 - 01:00
[X] 17/09/2022- 19:00 - 23:00
[X] 18/09/2022- 19:30 - 23:00
[X] 19/09/2022- 20:00 - 23:00
[X] 20/09/2022- 14:00 - 23:00
[X] 21/09/2022- 21:00 - 23:00
NOTE: If any of my times don't work for you, feel free to reach out and we can schedule an appointment for a different date.
Any psychiatrist/psychologist who can diagnose me and potentially give me medical help is fine.