User blog comment:Jake MultiSuperVids/The 2nd Official Full ERB Wiki Hurt/Heal/@comment-3401602-20141223010804/@comment-11419212-20141223041410

Well, TK, you will need to make an appointment. So if you'll sign it this form first, your heal can go through.
 * First name: ____________
 * Last name: ____________
 * Gender ___________
 * Date of birth: mm/dd/yy ____________


 * Daytime phone: ___________
 * Email: _______________________
 * Address: _____________
 * City: _____________
 * State/Province: ___________________
 * Zip/Postal code: ____________________
 * Country ________________
 * Department to schedule with: ______________

Jk, yeah, you can change your vote to "Heal Lexi, hurt Kari." 'Tis cool.
 * Patient's name, if appointment is not for you. _________________
 * How did you hear about us? TV Radio Newspaper Magazine Billboard Direct Mail Internet Advertising Email Health Lecture Relative/Friend Flier Other  (please specify)