[MEDICAL] Richard Zettici

[Richard Zettici]

I. PATIENT INFORMATION

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• Title: (select one)
  • [x] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Richard
  
  Middle Name: (optional)
  ANSWER
  
  Last Name:
  Zettici
  
  Gender: (select one)
  • [x] Male
  • [] Female
  Date of Birth:
  23/SEP/1961
  
  Address:
  6458 Power Street Apartment Complex - Apartment 5
  
  ZIP / Postal Code:
  026658
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [x] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  555-3425
  
  Email:
  N/A, prefer physical mail (( Flashforme ))
  

III. APPOINTMENT DETAILS

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• Has the patient been seen at Pillbox Hill Medical Center in the past?
  • [] Yes
  • [x] No
  Does the patient have a diagnosis?
  • [x] Yes
  • [] No
  If so, please describe:
  Diagnosed with leukemia, from personal general practitioner
  
  Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
  Start of treatment
  
  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.)
  • ((My time scheduele is a bit wonky, so I'd like to hear if you have some available times I can latch myself on to))
  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.)
  ANSWER