Texas Medical Mmarijuana Doctors

1. Patient Information Section

Enter Your Full Name

Date of Birth

Phone Number

Email Address

Residency

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

Address

Phone number

Month/Year of visit

Year Diagnosed

Upload diagnosis

Name of Provider

Address

Phone Number

Year Diagnosed

Upload diagnosis

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)

Yes No

Choose one of the following

Probation Parole Bond CPS Employment Accommodation Testing

Service option

4. Appointment Section

Day

Time

8AM-12PM 12PM-5PM

Congratulations

Thank you for registering with OnPatient. An OnPatient specialist will contact you within 1–2 hours to assist you with creating your patient portal account and completing the intake forms. If you have any questions in the meantime, please let us know.