[MEDICAL] Arnold Angel

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Arnold Angel
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[MEDICAL] Arnold Angel

Post by Arnold Angel »

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I. PATIENT INFORMATION
  • Title: (select one)
    • [X] Mr.
    • [] Mrs.
    • [] Ms.
    • [] Other
    First Name:
    Arnold

    Middle Name: (optional)
    N/A

    Last Name:
    Angel

    Gender: (select one)
    • [X] Male
    • [] Female
    Date of Birth:
    29/APR/1985

    Address:
    60 Lillith Foot Lane, Los Santos

    ZIP / Postal Code:
    TK02P0

II. CONTACT INFORMATION
  • Phone Type: (select one)
    • [X] Mobile
    • [] Home
    • [] Work
    • [] Other
    Phone Number:
    15951

    Email:
    [email protected] ((McDadda)) (( Include forum name in brackets ))

III. APPOINTMENT DETAILS
  • Has the patient been seen at Pillbox Hill Medical Center in the past?
    • [] Yes
    • [X] No
    Does the patient have a diagnosis?
    • [] Yes
    • [X] No
    If so, please describe:
    N/A

    Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
    SAPR Pre-requisite

    Is this condition or injury related to work?
    • [] Yes
    • [X] No
    Is this condition or injury related to an auto accident?
    • [] Yes
    • [X] No
    Department:
    • [X] Medical
    • [] Psychology
    • [] Phoenix
    Dates & Times for Appointment: (list your available dates and times in the next 7 days - use more lines if needed and mark with an 'X' your preferred one. Note that we cannot guarantee exact scheduling, but we will do our best to accommodate the patient's wishes.)
    • [X] 08/AUG/2021 - Anytime
      [] 09/AUG/2021 - 12PM - 4PM
      [] 10/AUG/2021 - 4AM to 6AM or 10PM to Midnight
      [] 11/AUG/2021 - 4AM to 6AM or 10PM to Midnight
      [] 12/AUG/2021 - 1AM to 5AM or 2PM to 11PM
    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.)
    N/A
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