[MEDICAL] Julian Peters

Moderator: Supervisors

Locked
Julian Peters
Visitor
Visitor
Posts: 3
Joined: Sun Aug 08, 2021 11:09 pm

[MEDICAL] Julian Peters

Post by Julian Peters »

Image

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

    Middle Name: (optional)
    Michael

    Last Name:
    Peters

    Gender: (select one)
    • [X] Male
    • [] Female
    Date of Birth:
    08/11/1996

    Address: 6834 Innocence Boulevard #6 Los Santos, San Andreas


    ZIP / Postal Code:
    90005

II. CONTACT INFORMATION
  • Phone Type: (select one)
    • [X] Mobile
    • [] Home
    • [] Work
    • [] Other
    Phone Number:
    8080763

    Email:
    [email protected] (( bigB3N710 ))

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 (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.)
    SAPR Evaluation

    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]
      [X] 13/08/2021 - 01:00-03:00
      [X] 14/08/2021 - 16:00-23:00
      [] 15/08/2021 - 15:00-19:00
    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
Locked