[MEDICAL] Ember Turner

[Kalani Castillo]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [x] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  EMBER
  
  Middle Name:[/i]
  
  
  
  Last Name:
  TURNER
  
  Gender: (select one)
  • [] Male
  • [x] Female
  
  Date of Birth:
  30/08/1998
  
  Address:
  3 Lindsay Circus - Floor 4, Room 6
  
  ZIP / Postal Code:
  
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [x] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  25799316
  
  Email:
  [email protected] (( MissAnarchy ))
  

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?
  • [x] Yes
  • [] No
  If so, please describe:
  Pregnancy
  
  Reason for Appointment: Please let us know why the patient needs this appointment. (i.e. symptoms or part of the body that is affected.)
  Confirmation of pregnancy and check up appointment. All home tests positive, missed period. Scan would be ideal.
  
  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:
  • [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.)
  • [] Any day or evening this week on server time. Anything that suits, as soon as possible.
  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.)
  Any. Preferably female.