Church Of Helm Clerical

Treatment Form 5b
Form 5b (Field Aid form) if seeking long term aid please use form 5a
Form to be completed prior to medical or clerical treatment of
individual or admission to prolonged intensive care. Treatment will
only be disbursed upon entire completion of form. We hold the right to
refuse service to anyone at anytime.
Date: ____________
completed By: ____________________________
Relationship to individual seeking treatment : ____________________________
Name :_________________________
Alias:________________________
Date Of Birth: ____________________
Race: _______________________
Occupation: ______________________
Mother maiden name:___________
In the Box; List all spells, Charm, blessings, Demonic/fey/Elder pack, Incantations,
former clerical Aid, Divine Interventions on behalf of planar deities, Mindflayer
induced fits of Amnesia, Severe injuries, loss of limb, Use of Artifacts, and Medications
or herbs used in the last six months:

Allergies:_________________________________________________________
Deity(please list any former Deities):____________________________________
Has the individual ever been treated for Vampirism, Lycanthropy, or Cursed? If so,
please list specific incident(s): _________________________________________
__________________________________________________________________
Emergency Contact Information: (If Different from individual filling out form)
Name: ____________________ Relationship to patient: ___________________
(Emergency contact information is required before treatment is given in case admittance
to Clinical facility. False information will lead to fine and stop of all treatment.
By signing and submitting this form patient consents that the church of helm or any
agent there of assigned to provide treatment is not responsible for side Effects, further
injury, curses, loss of limb, acts of wrath as committed by planar deities, portal rifts, or
death.
Signature: _______________________ Print in common: _______________________
Membership ID# _____________________ Do you wish to be resurrection if fatally
dismembered, or wounded : [ ] Yes [ ] No Date: ___________