1. Patient Information Section
Enter Your Full Name
Date of Birth
Phone Number
Email Address
Residency
Please Select
Texan
Non-Texan
Valid DL or ID Number
2. Qualifying Condition Selection
Qualifying Conditions (Please upload valid documentation)
Chronic Pain
PTSD
Cancer
Seizures
Arthritis
Other
Describe incident
Name of hospital/PCP/Urgent care/ Physical Therapist Or where did you receive the treatment?
Address
Phone number
Month/Year of visit
Year Diagnosed
Upload diagnosis
Name of Provider
Address
Phone Number
Year Diagnosed
Upload diagnosis/my chart
Name of Provider
Address
Phone Number
Name of Provider
Address
Phone Number
Upload Medications
Name of Provider
Address
Phone Number
Upload medications
Other
Please Call Our Office
1 (844) 832-4367
to speak to a medical professional.
3. Additional Qualification Question
Do you have to submit paperwork or take a drug test for anyone in an official capacity (i.e. lawyer, employer)
Yes
No
Choose one of the following
Probation
Parole
Bond
CPS
Employment Accommodation
Service option
Please select
$250 > Legal Prescription, CURT registration and additional accommodation letter for one year
Service option
Please select
$200 > Legal Prescription + CURT registration for one year
How were you referred to us?
Person
Google
Another Patient
Other
Patient Name
Write a Message
4. Appointment Section
Day
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Time
8AM-12PM
12PM-5PM
Type of Appointment
Please Select
In-person
Virtual
SUBMIT
1. Patient Information Section
Enter Your Full Name
Date of Birth
Phone Number
Email Address
Residency
Please Select
Texan
Non-Texan
Valid DL or ID Number
2. Qualifying Condition Selection
Qualifying Conditions (Please upload valid documentation)
Epilepsy
Seizure Disorder
Multiple Sclerosis
Spasticity
Amyotrophic Lateral Sclerosis
Autism
Incurable Neurodegenerative Disease
Traumatic Brain Injury
Terminal Illness, Hospice or Pallitive Care
Chronic Pain
PTSD
Cancer
Seizures
Arthritis
Other
Describe incident
Name of hospital/PCP/Urgent care/ Physical Therapist Or where did you receive the treatment?
Address
Phone number
Month/Year of visit
Year Diagnosed
Upload diagnosis
Name of Provider
Address
Phone Number
Year Diagnosed
Upload diagnosis/my chart
Name of Provider
Address
Phone Number
Name of Provider
Address
Phone Number
Upload Medications
Name of Provider
Address
Phone Number
Upload medications
Other
Please Call Our Office
1 (844) 832-4367
to speak to a medical professional.
3. Additional Qualification Question
Do you have to submit paperwork or take a drug test for anyone in an official capacity (i.e. lawyer, employer)
Yes
No
Choose one of the following
Court Proceeding
Probation
Parole
Bond
CPS
Employment Accommodation
Service option
Please select
$200 > Recertification Fee
Service option
Please select
$200 > Legal Prescription + CURT registration for one year
4. Appointment Section
Day
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Time
Morning
Afternoon
Type of Appointment
Please Select
In-person
Virtual
SUBMIT
Congratulations
Thank you for booking your appointment. A team member will contact you within 1-2 hours.