[MEDICAL] Terrance Lloyd

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Terrance Lloyd
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Joined: Mon Apr 04, 2022 10:22 pm

[MEDICAL] Terrance Lloyd

Post by Terrance Lloyd »

I. PATIENT INFORMATION
Title: (select one)
[x] Mr.
[] Mrs.
[] Ms.
[] Other
First Name:
Terrance

Middle Name: (optional)
Morgan

Last Name:
Lloyd

Gender: (select one)
[x] Male
[] Female
Date of Birth:
07/06/1987

Address:
Pink Cage Motel Room 27

II. CONTACT INFORMATION
Phone Type: (select one)
[x] Mobile
[] Home
[] Work
[] Other
Phone Number:
35846281

Email:
[email protected] (( DavkataBG ))

III. APPOINTMENT DETAILS
Has the patient been seen at Pillbox Hill Medical Center in the past?
[x] Yes
[] No
Does the patient have a diagnosis?
[x] Yes
[] No
If so, please describe:
Stage 3 Lung Cancer A

Reason for Appointment: Sperm Donation

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
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.)
[] 05/04/2022 - 18:00
[] 05/04/2022 - 19:00
[x] 05/04/2022 - 20:00
Preferred Doctor for Appointment: Gabriela Thorne
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