EFTX Intake Form
Fill out the Intake Form
If you meet the qualifications, you can fill out the intake below, and a clinic staff member will contact you. 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
-
Month
-
Day
Year
Date
Demographics
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Age
*
Gender
*
Please Select
Male
Female
Transgender Male/Trans Man/Female to Male
Transgender Female/Trans Woman/Male to Female
Genderqueer, neither exclusively male or exclusively female
Additional Gender Category
Decline to Specify
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African
Native Hawaiian or other Pacific Islander
White
Multi-Racial
Prefer not to specify
Other
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Decline to Specify
Primary Language
*
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Patient Contact Information
Email
*
example@example.com
Patient Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do we have your permission to text message you?
*
Yes
No
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Can we leave you a message?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Doctor and Medical Information
When were you diagnosed with epilepsy or seizure disorder?
*
Are you currently seeing a neurologist, doctor, primary care physician, or clinic that takes care of your epilepsy or seizures?
*
Yes
No
Sometimes
Yes, but haven't been in over a year
When was your last appointment with a neurologist/doctor/provider/clinic to take care of your epilepsy or seizures?
*
In the last five years have you been hospitalized or visited the ER due to your epilepsy or seizures?
*
Yes
No
Don't Remember
List all doctors/clinics and hospitals that have treated you for epilepsy or seizures in the last five years. Please be as specific as possible. List the doctor's name, hospital/clinic address, and month/year of visit. Put N/A if you cannot remember.
*
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Insurance Provider
Do you currently have any type of medical insurance?
*
Yes
No
Unsure
If you do have medical insurance, who is your current insurance provider?
i.e. Medicare, Medicaid, United Healthcare, BCBS, etc.
What is your yearly individual deductible for your current insurance?
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Final Steps
How did you hear about us?
*
Internet/Search Engine
Friend Referral
Social Media
Referral from Doctor or Clinic
Referral from Emergency Room or Hospital
TV/Radio
Third-Party Review
Other
Additional questions or comments
Submit
Should be Empty: