I. PATIENT INFORMATION
- Title: (select one)
- [X] Mr.
- [] Mrs.
- [] Ms.
- [] Other
Ezekial
Middle Name: (optional)
N/A
Last Name:
Young
Gender: (select one)- [X] Male
- [] Female
08/AUG/1993
Address:
105 Playa Vista, Del Perro
ZIP / Postal Code:
90291
II. CONTACT INFORMATION
- Phone Type: (select one)
- [X] Mobile
- [] Home
- [] Work
- [] Other
91275698
Email:
[email protected] (( getmoney ))
macrobian
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [] Yes
- [X] No
- [] Yes
- [X] No
ANSWER (N/A if the answer to the previous question is 'No')
Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
Needs to be evaluated for mental illness and psychological conditions. Patient was facing life in prison on a false charge and recently won his appeal. Prison experience has had psychological implications
Is this condition or injury related to work?- [] Yes
- [X] No
- [] Yes
- [X] No
- [] Medical
- [X] Psychology
- [] 23/AUG/2023 - 22:00 - 04:00
[] 25/AUG/2023 - 22:00 - 04:00
[] 26/AUG/2023 - 22:00 - 04:00
Mikey Lions