[PSYCHOLOGY] Phoebe Holter

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Phoebe Holter
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[PSYCHOLOGY] Phoebe Holter

Post by Phoebe Holter »

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

    Middle Name: (optional)
    N/A

    Last Name:
    Holter

    Gender: (select one)
    • [] Male
    • [X] Female
    Date of Birth:
    13/12/1992

    Address:
    102 Alta Street - Floor 3, Room 2

    ZIP / Postal Code:
    3165

II. CONTACT INFORMATION
  • Phone Type: (select one)
    • [X] Mobile
    • [] Home
    • [] Work
    • [] Other
    Phone Number:
    13912081

    Email:
    [email protected] (( books ))

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:
    ANSWER (N/A if the answer to the previous question is 'No')

    Reason for Appointment:
    I've been dealing with intense mood swings that last several weeks. I wasn't sure how serious this issue was but my recent actions associated with these mood swings have had such a destructive impact on my life that I would like some sort of evaluation because I feel I've lost control.

    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:
    • [] Medical
    • [X] 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.)
    • [] 17/08/2021 - 22:00 - 03:00 the next day.
      [] 18/08/2021 - 19:00 - 02:00
      [] 19/08/2021 - 19:00 - 02:00
    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
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