FreshRx Oklahoma Logo

Patient Application

Back to FreshRx website

Thanks for filling out the application for the FreshRx 'Food is Medicine' Program for North Tulsans living with Type 2 Diabetes!

We are currently working through a large waitlist, so this application helps us screen you. Unfortunately, it doesn't guarantee a spot in the program.

Enrollment can take up to three months. A FreshRx team member will follow up with you to perform the full enrollment process.

Note: By completing this application, you agree to be part of a research study evaluating the program. Participation in this study is completely voluntary and anonymous. The information you provide will be combined with responses from other individuals.

You may contact Erin Martin at erin@freshrxok.org if you have any questions about this research.

* This field is required.
* Please enter a valid email address.
* Enter a valid phone number OR check the box next to "I do not have a cell phone".
* Enter a valid phone number OR check the box next to "I do not have a home or work phone number".

Please select your zip code. Currently, we're serving residents of North Tulsa in the listed zip codes. If you're outside of our service area, please select "Other" and enter your zip code in the provided text field.

* Please select a zip code from the list. If you selected "Other", please enter a value.
* Please select a Clinic from the list. If you selected "Other", please enter the name of your clinic.
* Please enter the name of your primary care doctor.
* Please provide an answer.

Please select all that apply.

* Please select a value from the list. If you selected "Other", please enter a value in the text box.
Appliances

Which of these appliances do you have in your home to cook or store food?
Please check one box per line.

Yes, and it works
Yes, but it's not working
No
* Please provide an answer for each appliance.

Will you be able to attend regular clinic visits every three months to check your HbA1c?

* Please provide an answer.

We offer four classes per month for cooking and nutrition. Classes are both in-person and online that you can watch on your phone, tablet, or computer. Are you willing to participate in at least two classes per month?

* Please provide an answer.

Are you committed to staying in communication with our team about regular food pick-up and class attendance? (This is a required part of the program.)

* Please provide an answer.

Are you able to receive text messages?

* Please provide an answer.

Do you have transportation you can count on?

* Please provide an answer.
Thank you! We got your application.
A FreshRx team member will be in touch.
Oops! Something went wrong while submitting the form.