Forms are to be sent to email@example.com.
Open from Hours 9 to 18.
Code: Select all
[b]Full name[/b] (last then first):
[b]Age, if applicable[/b] (recommended):
[b]Height & Weight Estimates[/b] (or exact if applicable):
[b]Race[/b] (if applicable, HIGHLY recommended):
[b]Sex[/b] (Biologically born as/assigned at birth):
[b]Gender[/b] (What you identify as, wholly disparate from your biological/assigned sex):
[b]Preferred pronouns[/b] (In accordance with your gender, what pronoun (see: he/she, they/them, zie/xie, etc.) do you go by?):
[b]Past afflictions and/or current afflictions not relevant to current[/b] (if applicable, if any):
[b]Prior Occupation(s) if applicable:[/b]
[b]Are you taking any medicine/prescriptions/under any short-term/long-term treatment? If so, for what[/b]?:
[b]Allergies[/b] (if applicable, HIGHLY recommended):
[b]laplaceNET handle/Address (state continent, district, etc. if address):[/b]
[b]In detail below, please describe your symptoms as vividly and as coherently as possible. If no symptoms, please describe your purpose for seeking a consultation/treatment. Please be articulate:[/b]
OOC Note: Skype is Catastrophecupcakes. Can also P.M. this form.