PATIENT INFORMATION FORM
HOUSE OF GOD’S INFINITE HEALING
(formerly Providence Hospital)
Pursuant to the Religious Freedom Act of 2020, we are now authorized to ask you the following questions before deciding whether we are equipped to treat you at our facility, or will be forced to compel you out of it.
The information gathered will allow each of our medical professionals (i.e. doctors, nurses, residents, administrative, custodial, facilities, etc.) to assess the extent to which you meet his or her personal religious standards for medical treatment.
Please answer truthfully
God is watching
GENDER (choose only one):
Please do not write in additional responses.
Check all boxes that apply:
If you are female, answer the following questions. If you are male, skip to Section II.
Have you ever
□ had an abortion
□ thought about having an abortion
□ thought about someone else having an abortion
□ touched a condom
□ thought about a condom
□ used any form of birth control
□ spoken to anyone about birth control, approvingly or otherwise
□ considered sterilization (via “tube tying” or other abomination)
□ asked your parents how they feel about grandchildren
□ brought notarized permission from your husband to discuss your reproductive decisions
□ made any decisions regarding your or anyone else’s uterus without the approval of a male authority figure
□ never considered how sad you’ll be if you don’t fulfill your feminine destiny
□ heard the pernicious rumor that you actually might have a choice in the matter
Have you ever
□ had a sex change operation
□ knowingly touched anyone who has had a sex change operation
□ watched a movie in which someone discussed a sex change operation and not demanded your money back from the theater manager
□ considered how searingly hot the flames of hell are
The following questions are not strictly medical, but may have a bearing on the appropriateness of your particular doctor/patient relationship
Have you ever
□ baked a cake for a gay wedding
□ sold flour to someone who baked a cake for a gay wedding
□ fed corn to a chicken that laid an egg that was used in a cake for a gay wedding
□ been involved in any type of “fabulous” activity
□ peed in the “wrong” bathroom
□ even wondered what the other bathroom looks like
□ maybe peeked in through the crack in the door when someone of the opposite gender went into their God-given bathroom
□ questioned the motives of lawmakers who are just trying to save our blessed society, and know that the road to hell is paved with “civil rights”
After completion, please fold form to protect innocent eyes from any potential checkmarks and present to the staff behind the counter. After tabulating your responses, we will determine whether to schedule you for medical care or a prayer circle.
THANK YOU FOR YOUR COOPERATION
MAY GOD HEAL YOU IF WE CHOOSE NOT TO
Tara Campbell (www.taracampbell.com) is a writer, teacher, Kimbilio Fellow, and fiction editor at Barrelhouse. In addition to Queen Mob’s, her prior publication credits include SmokeLong Quarterly, Masters Review, Monkeybicycle, Jellyfish Review, Booth, Strange Horizons, and Escape Pod/Artemis Rising. She’s the author of a novel, TreeVolution, a hybrid fiction/poetry collection, Circe’s Bicycle, and a short story collection, Midnight at the Organporium. She received her MFA from American University in 2019.