Epilepsy Clinics

Safe, quality, and timely medical care for all.

The Epilepsy Foundation Texas Clinic Team, under Dr. Razi Rashid, MD, MPH, Interim Medical Director, offers specialized epilepsy medical treatment and medication management at our eight epilepsy clinics throughout the EFTX service area.

Our goal is simple: To ensure that all Texans with epilepsy have access to safe, quality, and timely medical care to treat their seizures.

Apply for Services Today!

1. Make Sure You’re Eligible

To become a new patient in our clinic, you must meet the following criteria:

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 intake@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.

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Date *

PATIENT DEMOGRAPHICS

Patient Name *

First

Last

Date of Birth *

Age *

Gender Identity *MaleFemaleTransgender Male/Trans Man/ Female-to-MaleTransgender Female/ Trans Woman/ Male-to-FemaleGenderqueer, neither exclusively Male nor FemaleAdditional gender categoryDecline to Specify

Race *American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RacialPrefer Not to SpecifyOther

Ethnicity *Hispanic or LatinoNot Hispanic or LatinoDecline to Specify

Primary Language *

PATIENT CONTACT INFORMATION

Email *

Cell Phone Number

Do we have your permission to text message you? *

• Yes
• No

Home Phone Number

Can We Leave a Message?

• Home
• Cell

Please tick all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

When were you diagnosed with epilepsy or seizure disorder? *

DOCTOR AND MEDICAL INFORMATION

Are you currently seeing a neurologist, doctor, primary care physician, or a 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 seizure in the last five years. Please be as specific as possible. List the doctor's name, hospital/clinic address, and month/year of visit. *

INSURANCE PROVIDER

Do you currently have any type of medical insurance? *

• Yes
• No
• Unsure

Current Healthcare Provider

What is your year individual deductible for your current insurance?

FINAL STEPS

How Did You Hear About Us?

• Internet/Search Engine
• Friend Referal
• Social Media
• Referral
• TV/Radio
• Third-Party Review
• Other

If other, please specify

Additional Questions or Comments

Submit