diff --git a/README.md b/README.md
index 069e4cd..140d81f 100644
--- a/README.md
+++ b/README.md
@@ -16,54 +16,7 @@ Visit http://localhost:3001/ to log in (use any username and password)
 Select a patient age, gender, indication, and order to determine whether it
 is within recommended guidelines.
 
-  <div>
-    <form action="evaluate" method="POST">
-      <table>
-        <caption>Enter Patient Demographics</caption>
-        <tr>
-          <th><label for="gender">Gender</label></th>
-          <td>
-            <select name="gender" required>
-              <option value="male">Male</option>
-              <option value="female">Female</option>
-              <option value="other">Other</option>
-            </select>
-          </td>
-        </tr>
-        <tr>
-          <th><label for="age">Age</label></th>
-          <td><input name="age" required></td>
-        </tr>
-        <tr>
-          <th><label for="indication">Indication</label></th>
-          <td>
-            <input list="indications" name="indication" required>
-            <datalist id="indications">
-              <option value="13213009">congenital heart disease</option>
-              <option value="25064002">headache</option>
-              <option value="279039007">lower back pain</option>
-              <option value="423341008">optic disc edema</option>
-              <option value="27355003">toothache</option>
-            </datalist>
-          </td>
-        </tr>
-        <tr>
-          <th><label for="procedure">Procedure</label></th>
-          <td>
-            <input list="procedures" name="procedure">
-            <datalist id="procedures">
-              <option value="75561">cardiac mri</option>
-              <option value="70450">ct scan - no contrast material</option>
-              <option value="71275">cta - with contrast material</option>
-              <option value="72133">lumbar spine ct scan</option>
-              <option value="70544">mra - head</option>
-            </datalist>
-          </td>
-        </tr>
-      </table>
-      <input type="submit">
-    </form>
-  </div>
+<img src="./images/empty_form.png" alt="alt text" width="256">
 
 V1 TODO
 -------
diff --git a/images/empty_form.png b/images/empty_form.png
new file mode 100644
index 0000000..630d852
Binary files /dev/null and b/images/empty_form.png differ