✪ Chip Removal Information ✪ [Form]
I, Cube, hereby state that I am capable of performing the surgical procedure needed to remove the modifier/limiter microchip.
Before filling the removal form below, I ask my patients to please make sure they have filled out a medical records form provided each month. If you need assistance in filling this form out or getting to the hospital, please contact me.
EFFECTIVE MAY 11th (2011) and onward: All applicants who complete this chip removal form:
Name: [Last , First]
Frequency: [Your Communicator Frequency]
Have you filled out the hospital medical records? [If "No", please provide reason why.]
Current State of Health: [Healthy, Sick w/cold, ect.]
Date of arrival or date of recent revival: [Date in which you arrived in Discedo/Fortuna or if you have died since your arrival, please state date in which you were revived.]
Emergency Contact Frequency: [This is the person whom will be contacted in case of an emergency]
What abilities will be unlocked: [Basic outline of Abilities. N/A if none present]
Name:
Frequency:
Have you filled out the hospital medical records?
Current State of Health:
Date of arrival or date of recent revival:
Emergency Contact Frequency:
What abilities will be unlocked:
((OOC: Be sure to fill out THIS DISCEDO MOD CHIP-REMOVAL FORM oocly. You must have spoken with Cube ICly or with myself OOCly before your character's chip removal will be approved. Feel free to contact me if there is a problem or if you have any questions.))
Before filling the removal form below, I ask my patients to please make sure they have filled out a medical records form provided each month. If you need assistance in filling this form out or getting to the hospital, please contact me.
EFFECTIVE MAY 11th (2011) and onward: All applicants who complete this chip removal form:
- Must respond to any questions themselves and not through a third party.
- Will be thoroughly examined and researched to the best of my abilities. This may include, but not limited to; pulling any medical records available, speaking with designated emergency contact, filtering through applicant's previous communications across the network. Personal opinions will not be sufficient in research.
- Must use the Safe House or have other plans to prevent harm to other residents.
Name: [Last , First]
Frequency: [Your Communicator Frequency]
Have you filled out the hospital medical records? [If "No", please provide reason why.]
Current State of Health: [Healthy, Sick w/cold, ect.]
Date of arrival or date of recent revival: [Date in which you arrived in Discedo/Fortuna or if you have died since your arrival, please state date in which you were revived.]
Emergency Contact Frequency: [This is the person whom will be contacted in case of an emergency]
What abilities will be unlocked: [Basic outline of Abilities. N/A if none present]
Name:
Frequency:
Have you filled out the hospital medical records?
Current State of Health:
Date of arrival or date of recent revival:
Emergency Contact Frequency:
What abilities will be unlocked:
((OOC: Be sure to fill out THIS DISCEDO MOD CHIP-REMOVAL FORM oocly. You must have spoken with Cube ICly or with myself OOCly before your character's chip removal will be approved. Feel free to contact me if there is a problem or if you have any questions.))