Operating Theater Patient Record

Name*:    E-mail*:

Please tell us more...(optional)
Your subject:     Select one... You make me feel so good!! Please send me info. Get me off your F@#$% mailing list! I want to be your sugardaddy. I want to volunteer. I want a meatball Tee-shirt! I just like to fill out forms. I have to ask a really dumb question.
Where does it hurt?      Select one... All over! My nodes are swollen. I'm allergic...to sh*t like this. I think I'm pregnant with your baby. I feel fine. I feel great! You feel great!
Can we get a second opinion?     Select one... Okay, you're ugly, too! I don't have an opinion. I'm just wasting time at work. I've wasted the best years of my life. End crass commercialism! Seriously, How can I give you money?

What do you like? (check all that apply)
piña coladas getting caught in the rain hospitals experimental theater Van Driver Garden of Forked Tongues The Present Perfect Nellie the psychic chicken Weird sh*t	tourists Transatlantica Are You ALIVE?! Hippies Dippies Kourtney Whippies Kenny Harry Meatbahl	thespians lesbians time travel Deer gameshows gumshoes FLAT! Dr. Schüler Nuttin'

How'd ya find us?
Google Facebook matchbook	ToNY Newspaper Friend	Paper Magazine Duh, I forget. Other (please specify)

Anything else?