Thank you for your interest in our services.
The information you provide is confidential and protected under the patient privacy law. If you should have any questions, please contact our office directly by phone at 504-345-2984 or email at email@example.com.
Prospective Patient Information
In order to best serve your needs, we will need additional information about the prospective patient. Please enter the requested information below.
Prospective Patient's Full First and Last Name
Is the prospective patient an Adult or Child?
Adult (18 and older)
Child (17 or younger)
Parent or Guardian's Name (FOR CHILDREN ONLY)
Prospective Patient's Date of Birth (month-date-year)
Prospective Patient's Mailing Address
Prospective Patient's Phone Number
Please enter a valid phone number.
What's the best time to call you back?
Prospective Patient's Email Address
Please note, we are not in network with the following insurances: Gilsbar, People's Health, Tricare. We are happy to see patients with these insurances, however, there may be an out of pocket cost if you decide to proceed with our services. Please call us for additional information.
Which type of insurance does the prospective patient have?
Aetna Better Health
Blue Cross/Blue Shield
Louisiana Health Care Connections
United Health Care
United Health Care Community Plan
Other insurance not listed
Please enter the patient's Insurance ID Number
Speech & Hearing Center Schedule
In order to best serve our patient's needs, we currently offer speech and hearing appointments in two locations: At our Uptown Office located at 4219 Magnolia Street (Tuesdays, Wednesdays, and Fridays) and at our Harahan Office located at 5640 Jefferson Hwy (Mondays and Thursdays). Hearing Aid related appointments with the Audiologist will be completed Uptown on Tuesdays or at our Harahan office on Mondays or Fridays.
Is the prospective patient a new patient?
Type of Appointment Needed
HEARING AID ADJUSTMENT
Which location would you prefer?
Which day of the week would you prefer?
Which times would you prefer?
What is the best number to send an appointment reminder text to?
Pediatrician/ Primary Care Physician's Name
Pediatrician/Primary Care Physician's Phone number
How did you hear about us?
Friends and Family
Pediatrician/Primary Care Physician
Is there any additional information that you would like us to know in order to best serve you?
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