I. PATIENT INFORMATION
- Title: (select one)
- [] Mr.
- [] Mrs.
- [✔] Ms.
- [] Other
Flora
Last Name:
Shala
Gender: (select one)- [] Male
- [✔] Female
09/03/1992
Address:
Integrity Hotel - Floor 5, Room 2
ZIP / Postal Code:
90017
II. CONTACT INFORMATION
- Phone Type: (select one)
- [✔] Mobile
- [] Home
- [] Work
- [] Other
4-6-4-6
Email:
ANSWER ((https://forum.gta.world/en/profile/55430-purplehaze/ ))
sleepz666
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [] Yes
- [✔] No
- [] Yes
- [] No
Bipolar
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
I need to see a therapist to cope with a breakup, threats, abandonment, work pressure, and alcohol-related issues.
Is this condition or injury related to work?- [] Yes
- [] No
- [] Yes
- [✔] No
- [] Medical
- [✔] Psychology
- [] DD/MMM/YYYY - HH:MM
[] 13/07/2023 - 18:00
[] 14/07/2023 - 18:00
[]15/07/2023 - 18:00
[]16/07/2023 - 18:00
Any