[MEDICAL] RICK HOLT

[Rick Holt]

I. PATIENT INFORMATION

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• Title: (select one)
  • [X] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Rick
  
  Middle Name: (optional)
  N/A
  
  Last Name:
  Holt
  
  Gender: (select one)
  • [X] Male
  • [] Female
  Date of Birth:
  25/02/1969
  
  Address:
  ANSWER
  
  ZIP / Postal Code:
  ANSWER
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  656 1747
  
  Email:
  [email protected] (( Raindance ))
  

(( Discord: ))
Raindance#1838


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?
  • [] Yes
  • [X] No
  If so, please describe:
  N/A
  
  Reason for Appointment: Need a rabies vaccination. I have been bit by a coyote suspected to be infected by rabies.
  ANSWER
  
  Is this condition or injury related to work?
  • [X] Yes
  • [] 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.)
  • [X] 06/06/2023 00:01 AM - 02:00 AM
    [] 06/07/2023 08:00 PM - 01:00 AM
  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