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 clinic@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

PATIENT LIFE DETAILS

Marital Status *SingleMarriedDivorcedWidowed

Are you currently employed? *

• Yes
• No

Patient Current Occupation and Employer

Patient's Current Monthly Income (Gross)? *

Have you been approved for disability/SSDI? *

• Yes
• No

EPILESPY AND SEIZURE INFORMATION

When were you diagnosed with epilepsy or seizure disorder? *

How old were you when you had your first seizure? If you don't know exact age, use your best estimate. *

What do your seizures typically look like? For example, do you lose consciousness and shake uncontrollably, do you stare, do you wander around, do you drop all the sudden, etc.? *

What is your typical seizure frequency? (pick the one that is the closest to your frequency) *Hundreds a day (staring)Several times a dayOnce a daySeveral Times a weekOnce a Week2 - 3 times a weekEvery Other MonthTwice A YearOnce A YearOnce Ever Couple of YearsHaven't had one in over three years.

When was your last seizure? *

How long did your last seizure last? *

Do you receive warning signs for your seizures *

• Yes
• No
• Unsure

What happens after your seizure? How long does it take to recover from your seizures? *

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. *

Are you currently taking any medications for your epilepsy or seizures? *

• Yes
• No
• Unsure

List all medications you are taking for epilepsy and seizures. Please be specific. List name of medication, dosage, instructions, and prescribing doctor.

Do use any of the following treatments for epilepsy or seizures?

• Vagal Nerve Stimulator (VNS)
• Responsive Neurostimulation (RNS)
• Medically Prescribed Ketogenic Diet
• Medically Prescribed Modified Adkins Diet
• CBD from the Texas State Compassionate Use Program

Have you had any brain surgeries for treatment of your seizures or epilepsy?

• Resection
• Hemispherectomy
• Deep Brain Stimulation
• Laser Ablation
• Radiosurgery
• Callosotomy

Do you have any allergies? *

• Yes
• No
• Unsure

List any known allergies here.

List your preferred pharmacy including name, phone number, and address. *

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?

Front of Insurance Card

Click or drag a file to this area to upload.

Back of Insurance Card

Click or drag a file to this area to upload.

Healthcare Provider Contact Information

Please add a contact phone number and email address

Subscriber

Relationship to Patient

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation to Patient *

May We Send Them Information? *NoYes

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