EFTX Online Clinic Intake

  • EFTX Intake Form

  • Fill out the Intake  Form

  • Clinic Eligibility Guidelines:

    • Have a current diagnosis of epilepsy or a seizure disorder,
    • Be a Texas resident living within our service area,
    • Not be enrolled in Medicaid or Medicare,
    • If privately insured, have a deductible that exceeds 5% of gross household income,
    • Have a gross household income at or below 200% of the Federal Poverty Level (FPL)

    If you meet the qualifications, you can fill out the intake below, and a EFTX will contact you with an application. Or you may call us toll-free at 1-888-548-9716, or e-mail us at bfrench@eftx.org. Our staff will work with you to establish an appointment and provide directions for the necessary documentation. We strive to schedule patients as quickly as possible.

  • Date
     - -

  • Demographics

  • Date of Birth*
     - -

  • Patient Contact Information

  • Format: (000) 000-0000.
  • Do we have your permission to text message you?*
  • Format: (000) 000-0000.
  • Can we leave you a message?*

  • Doctor and Medical Information

  • Are you currently seeing a neurologist, doctor, primary care physician, or clinic that takes care of your epilepsy or seizures?*
  • Are you currently taking medication(s) for epilepsy or seizures?*
  • In the last five years have you been hospitalized or visited the ER due to your epilepsy or seizures?*

  • Insurance Provider

  • Do you currently have any type of medical insurance?*

  • Final Steps

  • How did you hear about us?*
  • Should be Empty: