Patient Questionnaire

1. Name: ____________________________________

2. Next of Kin: _____________________________________

3. Alternate Next of Kin: _________________________________

4. Do you have a lawyer? Yes □ No □            5. Are you a lawyer? Yes □ No □

6. If YES to either 4 or 5, are you or do you have a GOOD lawyer? Yes □ No □

7. Have you ever seen Dr. Zoidberg before? Yes □ No □

8. If YES to 7, explain your survival: ________________________________________

9. Are you a reporter or undercover journalist? Yes □ No □

10. Please select the outcome(s) for your visit today that are least objectionable to you:

□ Death           □ Coma             □ Decapitation     
□ Paralysis       □ Death            □ Blindness
□ Amputation      □ Sterility        □ Death

11. If you DID NOT select death in 10, would it be acceptable anyway? Yes □ No □

12. What is your main reason for seeing the doctor today? _________________________

13. Do you realize that the condition you described in 12 could result in your death in the very near future, like while Dr. Zoidberg is treating you? Yes □ No □

Finally, by signing below, you certify that you understand the risks of partaking in medical treatment by Dr. Zoidberg. These risks include, but are not limited to; death, dismemberment, pain, suffering, loss of any number of motor functions, loss of memory, gain of memory, loss of bladder control, loss of organs, crippling psychological damage, plain old crippling, and ringing in the ears. You also certify that any and all improvement in your condition is purely coincidental. Dr. Zoidberg takes no responsibility for articles left unattended while you are anesthetized; this includes, but is not limited to, wallets, credit cards, car keys, breath mints, gum, lint or actual food. All payment is due BEFORE seeing the doctor.

Signature ____________________________________ Date ____________________