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
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
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
Congratulations
Thank you for booking your appointment. A team member will contact you within 1-2 hours.