(Form 666)
You [PATIENT NAME], have the right to be informed about
your condition(s), heretofore referenced as THE CONDITION
(circle the below as appropriate):
- Leprosy
- Fantasmagoria
- Galvanism
- Idiopathic Nosophobia
- Other: __________
and the recommended treatment so that you can make an informed decision
whether or not to
undergo [THE PROCEDURE]
This disclosure is not meant to
A l a r m y o u but is rather an effort to properly inform you
We will make every effort to assure that you are fully informed and fully waylaid
Although the
Shelley Concepts Inc custom patient-fitted reconstruction prosthesis
has undergone preliminary in vivo in mortuus testing (and improved results are anticipated!)
I, [PATIENT NAME],
am aware that results also depend upon my adherence to
the post-operative rehabilitation program
which includes (but is not limited to):
A. Change in Diet: Strict liquid diet of Ecto-Coolers and Whole Organic [Human] Bone Broth.
B. Physical Therapy/Exercise: Avoid moving Facial Muscles, especially those expressing Emotion(s).
C. Avoiding: Reflective Surfaces, Radio Frequency Emitting Devices, Human Contact, Snow, Air Travel, Smoking, Alchemy and its Practitioners, Fire and Virtual Fireplaces, Love, etc.
D. Social Distancing: Restricting movement to Tree Hollows, Stone Cellars, Castle Ruins, Granite Fissures, Abandoned Mine Shafts, Volcanic Vents, AOL Chat Rooms, Enchanted Wells to the Underworld.
am also aware that it may not be entirely possible to eliminate
side effects which include but are not limited to
allergic reaction to the prosthesis bruising objectionable scarring adhesions ankylosis general hideousness stifling discoloration of the eyes jaw ear inflammation of the canal perforation of the permanent numbness conjunctivitis ringing in the brain equilibrium continued dysfunction decreased derange of motion nausea difficulty breathing cramping tingling diarrhoea spontaneous birth contractions rash of the extremities internal bleeding possibly requiring later revision
and that the underlying causes that necessitate
a complete facial reconstruction with Shelley Concepts Inc!
custom FACIAL patient-fitted FACIAL reconstruction FACIAL prosthesis
your hideous face hideous face hideous face hideous hideous face hideous hideous hideous
will not can not won’t not be fully addressed by
THE PROCEDURE
and agree to hold harmless not sue for any reason in perpetuity for all of time ever ever ever
Shelley Concepts Inc. and their
employees, employee’s spouses, international holding company, investors, social media intern
I, [PATIENT NAME], out of wantonness, do authorize Dr. [NAME] and Shelley Concepts Inc. (do not deny me my request!) to assuredly perform THE PROCEDURE (that I so ardently desire) in order to gain a small portion of the happiness (advancement of the night! most abhorred task!) which I believe
I am owed.
[PATIENT’S SIGNATURE HERE – G O D S P E E D !]
Katie R. Yen writes fiction and poetry through a multicultural lens. Her work has been published in Edible East Bay, Fathom Magazine, Third Coast, America and Snarl, and she is the winner of the 2022 International Sijo Competition hosted by the Sejong Cultural Society. She studied linguistics and foreign languages at Swarthmore College, and you can find her muttering in Spanglish and Chingrish while battling aphids on her roses. For more of her work, visit www.katieyen.com and follow her @katiedowrite.
