Forms are to be sent to email@example.com.
Open from Hours 9 to 18.
Full name (last then first):
Age, if applicable (recommended):
Height & Weight Estimates (or exact if applicable):
Race (if applicable, HIGHLY recommended):
Sex (Biologically born as/assigned at birth):
Gender (What you identify as, wholly disparate from your biological/assigned sex):
Preferred pronouns (In accordance with your gender, what pronoun (see: he/she, they/them, zie/xie, etc.) do you go by?):
Past afflictions and/or current afflictions not relevant to current (if applicable, if any):
Prior Occupation(s) if applicable:
Are you taking any medicine/prescriptions/under any short-term/long-term treatment? If so, for what?:
Allergies (if applicable, HIGHLY recommended):
laplaceNET handle/Address (state continent, district, etc. if address):
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:[/code]
OOC Note: Skype is Catastrophecupcakes. Can also P.M. this form.