Name *

First Name

Last Name

Phone *

Whenever you see the number 999-999-9999, please answer the phone. We’ll be in touch

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For those suffering from multiple ailments, please select your top 3:

1. Chrono Cramps – Sudden muscle spasms whenever the timeline shifts.

2. Tachyon Toe – Your toes get stuck one second ahead of the rest of your body.

3. Retroflux – Severe heartburn from eating food that hasn’t been invented yet.

4. Paradox Pox – Mysterious spots appear if you accidentally meet your past self.

5. Future Flu – Symptoms you won’t recognize until next week.

6. Hells Bells– Constant ringing sound from overlapping alternate timelines.

7. Epoch Eczema – Skin rash caused by allergic reaction to the 14th century.

8. Deja-Viral – Infectious disease that makes you relive the same cough over and over.

9. Quantum Queasiness – Nausea caused by too much jumping between centuries.

10. Past-Life Lice – Lice that hitchhike from medieval peasants into your hair.

11. Causality Cough – You start coughing before you actually get sick.

12. Flux Foot – One foot ages faster than the other.

13. Chrono-Colon – Your digestive system loops breakfast indefinitely.

14. Inverse Insomnia – You only sleep well in years you were never born.

15. Turbs– Dizzy spells triggered by timeline turbulence.

16. Butterfly Effect Blisters – Every time you mess up history, you break out in hives.

17. Wrecko-Echoes – You hear echoes of arguments you haven’t had yet.

18. Oxynoxy – Can’t breathe air from centuries where you don’t belong.

19. Loop-throat – You lose your voice if you say something that alters history.

20. Temporal Hemorrhoids – Don’t ask how these work.

IF yes, please inform us if you’ve dared the following:

1. A live rebel gathering some dare to call a concert performance by the ELECTRIC LADY NUMBER ONE

2. The Dirty Computer emotion picture by Django Jane

3. Audio recordings by the freeasmuthafucka Janelle Monàe

4. The Memory Librarian book by Jane 57821