OFFICIAL LEAD SUBMISSION

CLIENT DOB
CPN
HIT DROPDOWN
LEAD VENDOR
HIT DROPDOWN
LEAD TYPE
HIT DROPDOWN
LEAD CLOSED ON

By checking this box, I confirm that the information provided is accurate to the best of my knowledge and I authorize Texas Compound to contact the lead submitted for the purpose of providing services, coverage options, or follow-up communication. I understand I am responsible for submitting only legitimate, consented leads.

By checking this box, I acknowledge that the information submitted may be stored, tracked, and used by Texas Compound for internal review, performance tracking, and communication purposes. I consent to this data being logged and monitored as part of the lead submission process.