Concussion in hospital now

[IsaDef1]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • [Y] Ms.
  • [] Other
  First Name:
  Isabella
  
  Middle Name: (optional)
  ANSWER
  
  Last Name:
  Defonzo
  
  Gender: (select one)
  • [] Male
  • [Y] Female
  Date of Birth:
  20/04/1993
  
  Address:
  3402 Magellan Avenue Floor 1 Room 7
  
  ZIP / Postal Code:
  ANSWER
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [Y] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  87142219
  
  Email:
  [email protected] ((Isabella Defonzo))
  

(( Discord: ))
Tehryn121#2215


III. APPOINTMENT DETAILS

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• Has the patient been seen at Pillbox Hill Medical Center in the past?
  • [Y] Yes
  • [] No
  Does the patient have a diagnosis?
  • [] Yes
  • [Y] 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.)
  Possible concussion after being beaten by thugs
  
  Is this condition or injury related to work?
  • [] Yes
  • [Y] No
  Is this condition or injury related to an auto accident?
  • [] Yes
  • [Y] No
  Department:
  • [Y] 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] 12/05/2023 - 12:00
    [X] 13/05/2023 - 12:30
    [] DD/MMM/YYYY - HH:MM
  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.)
  ANSWER