[FORM] Appointment Request 📝

[Evelyn Bleichroder]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  ANSWER
  
  Middle Name: (optional)
  ANSWER
  
  Last Name:
  ANSWER
  
  Gender: (select one)
  • [] Male
  • [] Female
  Date of Birth:
  DD/MMM/YYYY
  
  Address:
  ANSWER
  

II. CONTACT INFORMATION

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• Phone Number:
  ANSWER
  
  Email:
  ANSWER (( Include forum name in brackets ))
  
  (( Discord: ))
  ANSWER
  

III. APPOINTMENT DETAILS

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• Has the patient been seen at Pillbox Hill Medical Center in the past?
  • [] Yes
  • [] No
  Does the patient have a diagnosis?
  • [] Yes
  • [] 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. eval, check-up, symptoms or part of the body that is affected.)
  ANSWER
  
  Department:
  • [] Medical
  • [] Dental
  • [] Mental Health
  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.)
  • [] DD/MMM/YYYY - HH:MM
    [] DD/MMM/YYYY - HH:MM
    [] DD/MMM/YYYY - HH:MM
  Preferred Doctor for Appointment: (check the list of practitioners 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.)
  ANSWER

[Evelyn Bleichroder]

Title Template:

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[MEDICAL/PSYCH/EVAL/DENTAL] YOUR FULL NAME

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[divbox=grey][center][img]https://i.imgur.com/s5acD6S.png[/img][/center][/divbox]
[divbox=white]
[br][/br][color=#BF0000][size=150][b]I. PATIENT INFORMATION[/b][/size][/color][hr][/hr]
[list=none][b]Title:[/b] [i](select one)[/i]
[list=none][] Mr.
[*][] Mrs.
[*][] Ms.
[*][] Other[/list]
[b]First Name:[/b]
[i]ANSWER[/i][br][/br]
[b]Middle Name:[/b] [i](optional)[/i]
[i]ANSWER[/i][br][/br]
[b]Last Name:[/b]
[i]ANSWER[/i][br][/br]
[b]Gender:[/b] [i](select one)[/i]
[list=none]
[*][] Male
[*][] Female[/list]
[b]Date of Birth:[/b]
[i]DD/MMM/YYYY[/i][br][/br]
[b]Address:[/b]
[i]ANSWER[/i][br][/br][/list]
[br][/br][color=#BF0000][size=150][b]II. CONTACT INFORMATION[/b][/size][/color][hr][/hr]
[list=none][b]Phone Number:[/b]
[i]ANSWER[/i][br][/br]
[b]Email:[/b]
[i]ANSWER (( Include forum name in brackets ))[/i][br][/br]
[b](( Discord: ))[/b]
[i]ANSWER[/i][br][/br]
[/list]
[br][/br][color=#BF0000][size=150][b]III. APPOINTMENT DETAILS[/b][/size][/color][hr][/hr]
[list=none]
[b]Has the patient been seen at Pillbox Hill Medical Center in the past?[/b]
[list=none]
[*][] Yes
[*][] No[/list]
[b]Does the patient have a diagnosis?[/b]
[list=none][*][] Yes
[*][] No[/list]
[b]If so, please describe:[/b]
[i]ANSWER (N/A if the answer to the previous question is 'No')[/i][br][/br]
[b]Reason for Appointment:[/b]
[i]ANSWER[/i][br][/br]
[b]Department:[/b]
[list=none]
[*][] Medical
[*][] Dental
[*][] Mental Health[/list]
[b]Dates & Times for Appointment:[/b] 
[list=none][] DD/MMM/YYYY - HH:MM
[] DD/MMM/YYYY - HH:MM
[] DD/MMM/YYYY - HH:MM[/list]
[b]Preferred Doctor for Appointment:[/b]
[i]ANSWER[/i]