New Patient Registration - Ascend Speech & Swallow
Please complete the attached form below. We will call you to schedule your initial appointment as soon as possible. We are looking forward to helping you reach your goal to a better quality of life. Please contact us at (513) 935-0535 or amanda@ascend-speech.com if you have any questions. Thank you.
Client/Patient First and Last Name
Who is filling out this form?
Client/Patient
Family Member/Legal Guardian
Client/Patient Date of Birth
Phone Number
Email
Client/Patient Home Address
Primary Care Physician
Please provide (1) name of Primary Insurance information and (2) Member ID.
If applicable: Please provide (1) name of Secondary Insurance information and (2) Member ID.
Are you or your loved one currently receiving any other in-home care?
Yes
No
Scheduling Preference
Morning (AM)
Afternoon (PM)
No preference
Which services are you seeking?
Communication therapy (speech and/or language)
Voice (Speak Out! by Parkinson's Voice Project)
Swallowing therapy
Cognitive retraining
Please provide a brief description of the problems you/your loved one have been experiencing:
Submit
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