NAPA Prescription Request Form
If you would like NAPA to send a prescription request to your child's physician for therapy, complete the form below.
Clinic
*
Austin, TX
Boston, MA
Los Angeles, CA
Therapy Program
*
Weekly
Intensive
Therapy Type (please select all therapies in which your child will be participating)
*
Physical Therapy
Occupational Therapy
Speech Therapy
VitalStim
Hyperbaric Oxygen Therapy
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
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Physician's Name
*
First Name
Last Name
Physician's Phone Number
-
Area Code
Phone Number
Physician's Fax Number
*
-
Area Code
Phone Number
Physician's Email
example@example.com
Submit
Should be Empty:
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