[MEDICAL] Ezra Ferreira

[Ezra Ferreira]

I. PATIENT INFORMATION

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• Title: (select one)
  • [X] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Ezra
  
  Middle Name: (optional)
  N/A
  
  Last Name:
  Ferreira
  
  Gender: (select one)
  • [X] Male
  • [] Female
  Date of Birth:
  01/09/1997
  
  Address:
  San Andras Avenue Apartments, Floor 8, Room 1
  
  ZIP / Postal Code:
  90017
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  1525
  
  Email:
  [email protected] (( babygoat ))
  

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
  
  Reason for Appointment:
  I am unable to grow a beard and I need to grow one for a modeling job, I was told to check for a potential hormonal imbalance.
  
  Is this condition or injury related to work?
  • [X] Yes
  • [] 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] 07/12/2022 - 18:00 or later
    [] 08/12/2022 - 13:00 or later
    [] 11/12/2022 - 13:00 or later
  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.)
  Whoever is available on the earliest possible date.