I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [X] Ms.
- [] Other
AMAHLE (or "Amma")
Middle Name: (optional)
HOPE
Last Name:
MTHEMBU ("Muh-TEMM-boo")
Gender: (select one)- [] Male
- [X] Female
02/OCT/2000
Address:
2362 Bridge Street - Floor 1, Room 1
ZIP / Postal Code:
(( N/A ))
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
2898 5848
Email:
saffronmthembu@gmailcom (( "Afthaire" on forums. Email is real, but please let me know if you use it!))
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [X] Yes
- [] No
- [X] Yes
- [] No
Severe nut and opioid allergy, bruxism, previous diagnosis of Acute Stress Disorder.
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
My cynophobia is ongoing and I have not heard from my assigned therapist in many months ((deleted account)).
Is this condition or injury related to work?- [X] Yes
- [] No
- [] Yes
- [X] No
- [] Medical
- [X] Psychology
- [X] Any days except November 27th and December 2nd; 19:00 - 02:30am.
Sade Aliz/Felicity Scott