Pillbox Hill Medical Center

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • [X] Ms.
  • [] Other
  First Name:
  Naomi
  
  Middle Name: (optional)
  
  
  Last Name:
  Kansaki
  
  Gender: (select one)
  • [] Male
  • [X] Female
  Date of Birth:
  05/JAN/2002
  
  Address:
  3 Lindsay Circus, Little Seoul
  
  ZIP / Postal Code:
  90016
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  16991064
  
  Email:
  [email protected] (( Twennyone ))
  

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:
  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.)
  I have serious psychological problems, due to a certain incident.
  After this happened, I was referred by a friend to Doctor Sade Aliz,
  who in turn referred me online to the "Request an appointment" website.
  
  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:
  • [] Medical
  • [X] 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] 25/JUN/2022 - 20:00 : 03:00
    [X] 26/JUN/2022 - 16:00 : 03:00
    [X] 27/JUN/2022 - 16:00 : 03:00
    [] 28/JUN/2022 - 16:00 : 03:00
    [] 29/JUN/2022 - 16:00 : 03:00
    [] 30/JUN/2022 - 16:00 : 03:00
    [] 01/JUL/2022 - 16:00 : 03:00
  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.)
  Sade Aliz, Psy.D.

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Dear Ms. Naomi Kansaki,

Thank you for reaching out to us and for your request.

My earliest available date would be July 6th or July 7th at 17:00. Please let me know if either of these dates work for you.

If you would like to meet earlier, please let me know and I will match you up with another of our caring professionals.

Kind regards,
Dr. Sade Aliz
Psychology Department
Pillbox Hill Medical Center

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Dear Naomi Kansaki

We have received and reviewed your request and we are delighted to inform you that your appointment is scheduled on 06/JUL/2022 at 17:00 with Doctor Sade Aliz. Please make sure to:

1. Park your vehicle on the southern parking lot on Strawberry Avenue.
2. Enter through the northern entrance on Elgin Avenue which leads directly to the lobby and front desk.
3. Show up at least fifteen minutes prior to the appointment time.
4. Check in at the reception and patiently wait in the lobby.

Kind regards,

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Dear Ms. Naomi Kansaki,

Please update your times and dates of availability to match you with one of our caring professionals immediately.

Kind regards,
Dr. Sade Aliz
Psychology Department
Pillbox Hill Medical Center

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Dear Naomi Kansaki

Thank you for reaching out to us and for your request. As advised my earliest available appointment is 21/JUL/2022 at 17:00.

Per your request, you have confirmed this time slot.

Please make sure to:

1. Park your vehicle on the southern parking lot on Strawberry Avenue.
2. Enter through the northern entrance on Elgin Avenue which leads directly to the lobby and front desk.
3. Show up at least fifteen minutes prior to the appointment time.
4. Check in at the reception and patiently wait in the lobby.

Kind regards,