[Medical] Dakota Woods

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Dakota Woods
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Joined: Thu Aug 26, 2021 11:14 pm

[Medical] Dakota Woods

Post by Dakota Woods »

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

    Middle Name: (optional)
    N/A
    N/A
    Last Name:
    Woods

    Gender: (select one)
    • [] Male
    • [X] Female
    Date of Birth:
    15/04/1999

    Address:
    2140 Senora Freeway

    ZIP / Postal Code:
    6008

II. CONTACT INFORMATION
  • Phone Type: (select one)
    • [X] Mobile
    • [] Home
    • [] Work
    • [] Other
    Phone Number:
    1068

    Email:
    [email protected] ((Fancy Toothpaste on the forums/FancyToothPaste#3181 on Discord))

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.)
    Going on 41 Weeks pregnant, experiencing early contractions and signs of early labor. Looking to be seen as soon as humanly possible.

    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] 26/08/2021 - 20:00 to 06:00 (Server time)
      [X] 27/08/2021 - 20:00 to 06:00 (Server time)
      [] 29/08/2021 - 20:00 to 06:00 (Server time)
      [] 30/08/2021 - 20:00 to 06:00 (Server time)
      [] 31/08/2021 - 20:00 to 06:00 (Server time)
      [] 01/09/2021 - 20:00 to 06:00 (Server time)
      [] 02/09/2021 - 20:00 to 06:00 (Server time)
    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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