Primary Care Intake Form – DarkDan Laboratories

Thank you for your interest in establishing Dr. DarkDan as your Primary Care Physician. Please take a few minutes to fill out our new patient paperwork. This will help ensure our staff can quickly and efficiently add you to our list of ~~victims~~ patients.

Seriously, we’re going to make a fun “testimonials” section. Have fun with it.

Your legal name (Tell me who you really are, this stays between us...)

Your email (Just so I can confirm your not a bot, this stays private)

I would like to receive a free test kit including a DarkDan Labs sticker.

Your alias (This is what you will appear as on our web site, be as funny as you want.)

I agree to your outrageous Terms & Conditions.I agree to pay every bill I receive.I agree that, as my primary care physician, Dr. DarkDan has complete control in my final wishes, the name of my third child, and the rights to any song which I have sung in my entire life.
Insurance (Required, because I wanna get paid)

What health concerns caused you to seek out Dr. DarkDan (be funny):

Your testimonial (if you've already been to DarkDan Laboratories, please write a testimonial) (optional, and can be completely fictitious)

Your photo (optional)

I understand this photo will be used to create a funny AI photo of me. DarkDan will send it to me before posting for my review.