VETERAN CBD/THC TELEMEDICINE INTAKE FORM

This form and pricing is for Veteran's ONLY.

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Patient Contact Information

*Note you MUST be located in Texas and/or Oklahoma USA in order to qualify for our service.

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Guardian Information

If the patient is underage then input all of the guardian's information below.


Medical Information
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Appointment Details
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If you need more information about the qualifying conditions then Dr. Straface will discuss the 168 conditions with you during the tele-medicine call.

Medical Disclaimer 
NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.
Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at THC MD TELEMED
Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out our medical questionnaire. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am paying for a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Important:

  • You may inquire yourself with your own insurance company about reimbursement. We do not take insurance at this time.
  • The consultation fee does not include the cost of the medication prescribed. 
  • Also, if you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our THC MD TELEMED Team members will assist. Thank you! Phone: 682-353-8426
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Sub Total
$180.00
TOTAL
$180.00

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Thank you for Telemedicine Order

Thank you for your Telemedicine Appointment with Dr. Straface. Please allow up to 24 hours for this to be completed. 

Next Steps:

1. Upon telemedicine completion with Dr. Straface, our staff will complete and add your prescription to the Texas Department of Public Safety website.

2. Please allow up to 48 hours for this to be completed. 

3. Once your prescription is registered with the Texas Department of Public Safety, you will contact the dispensary of your choice to complete your prescription order. 

4. There are two dispensaries in the State of Texas that you can order directly from once your prescription is registered. We encourage you to look at both dispensaries and decide which products you prefer. Special note: Each dispensary carries different products and flavors, so we recommend contacting their customer service representatives and/or browsing their websites. 

5. Upon making your dispensary selection, you will be responsible for purchasing your order and making the payment directly to your preferred dispensary.

Dispensary Contact Information Below:

https://www.thcmdtelemed.com/texas-dispensaries

Please use your interactive patient portal to message us if you have any questions or concerns. 

Thank you!

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