Clinic Appointment Request Form [RETIRED]

⚠️ This form has been updated.
Please use the new version here:
🔗 https://form.jotform.com/260499029428163

Deactivated?
Clinic Appointment Request Form

⚠️ PLEASE READ ⚠️ We have two upcoming clinics. The dates are April 18th (VIRTUAL) & May 2 (at Towson Library located at 320 York Rd, Towson, MD 21204). Please carefully select your appointment slot to make sure you are selecting the correct date, location and time.
Request a clinic slot*
Name*

First NameLast Name
Email*
example@example.com
Pronouns*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you live in?*
Birthday*

MonthDayYear
Date
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Race*
What type of artist are you?*
Detailed description of legal issue*
What type of legal issue are you having?*
Do you have any files or documents that may need further review by an attorney?*

YesNo
Do you have a digital copy of these files or documents?*

YesNo
Documents over five pages will not be accepted. Please upload the document here. *

Cancelof
I understand and certify that I will attend at my confirmed appointment time.*

Yes, I will attend my clinic appointment on April 18th on ZoomYes, I will attend my clinic appointment on May 2nd at 320 York Rd, Towson, MD 21204No, I will cancel my clinic appointment and wait for the next clinic opportunity
I will monitor my email address used to complete this form for communications from MDVLA staff members before my clinic appointment.*

Yes, I will monitor my emailNo, I will cancel my clinic appointment
Should be Empty: