[MEDICAL] Daniel Lupshitz

[Eddie Douglas]

I. PATIENT INFORMATION

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• Title: (select one)
  • [x] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  DANIEL
  
  Middle Name: (optional)
  N/A
  
  Last Name:
  LUPSHITZ
  
  Gender: (select one)
  • [X] Male
  • [] Female
  Date of Birth:
  04/AUG/1990
  
  Address:
  Room 26, Pink Cage Hotel
  
  ZIP / Postal Code:
  N/A
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [x] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  44551881
  
  Email:
  ((Matuze))(( Include forum name in brackets ))
  

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:
  N/A(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.)
  Physical evaluation for employment
  
  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.)
  • [x] 03/SEP/2022 - 11:00 AM - 9:00 PM
    [x] 04/SEP/2022- 9:00 AM - 6:00 PM
    [] 05/SEP/2022- 5:00 PM - 8:00 PM
  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.)
  N/A