I. PATIENT INFORMATION
- Title: (select one)
- [X] Mr.
- [] Mrs.
- [] Ms.
- [] Other
Doni
Middle Name: (optional)
Last Name:
Provacci
Gender: (select one)- [X] Male
- [] Female
21/AUG/1998
Address:
North Archer Avenue - Apartment Complex - Floor 8, Room 1
II. CONTACT INFORMATION
- Phone Number:
6776225
Email:
[email protected] (( EKWorks ))
(( Discord: ))
ekworks
III. APPOINTMENT DETAILS
- Has the patient been seen at Pillbox Hill Medical Center in the past?
- [] Yes
- [X] No
- [] Yes
- [X] No
N/A
Reason for Appointment:
Provacci has sustained multiple gunshot injuries and permanent disfigurement following a mass shooting, and seeks to receive a professional assessment of his injuries and a comprehensive report authored by a physician.
Department:- [X] Medical
- [] Dental
- [] Mental Health
- Monday-Thursday, 14:30 - 20:00;
Friday-Saturday, 14:30 - 23:59;
Sunday, 14:30 - 20:00.
Nicholas Pazzi, M.D.
Yara Haddad, M.D.
This appointment request is submitted by legal counsel for Doni Provacci with the consent of Doni Provacci. Any and all further correspondence should be sent directly to Doni Provacci, otherwise any and all further correspondence received by the attorney, Joseph Katz, will be forwarded to Doni Provacci by the attorney and deleted from the attorney's records pursuant to preserving confidentiality. /s/ Joseph Katz (Augury Office Complex Fl2, Rm3) (Ph# 360-09-682)