Please provide an email address for a representative at your treating facility if you wish to complete the Verification Form using DocuSign.
Please note that at this time we are only enabled to serve patients in the Central Texas region.
We require at least one email contact. If the patient does not have an email address, please provide Guardian/Caregiver email address.
Lets get your profile shared! We encourage you to send it to all your family and friends. Please list Name, Relationship to Patient & Email address (separated by comma). We will email them once your profile is complete.