Information Request Form
Parent/Caregiver Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
Date
Caregiver Email
*
example@example.com
Caregiver Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Interested In:
*
Please Select
Infant Feeding Therapy (0-6 months)
Pediatric Feeding Therapy (6 months+)
Early Oral Motor/Myofunctional Therapy (less than 4 years old)
Myofunctional Therapy (5 yo+)
Location
*
Hollywood
Ft. Lauderdale
Aventura
North Miami Beach
Coral Springs
Deerfield Beach
Parkland
Miami Beach
Boca Raton
Other
Zipcode:
*
My child has the following symptoms (click all that apply):
*
Bottle/Breastfeeding Challenges
Picky Eating/Texture Aversion
Oral Motor Weakness/Drooling
Tongue/Lip Ties
Starting or Progressing through Solids
Faliure to Thrive
G-tube/n-g tube transition
Myo: Thumb Sucking
Myo: Sleep Disordered Breathing
Myo: Drooling
Myo: Open Mouth Breathing
Myo: Tongue Thrust/Lisps
Other
We are not in-network with any insurance plans. All services are private pay. We gladly accept Step Up for Students (FES-UA Scholarship), as well as FSA and HSA payments. If you would like to seek reimbursement from your insurance company, we can provide a superbill for you to submit directly to your carrier.
*
Yes
I plan to use my FES-UA Scholarship for payment (3 years old +)
*
Yes
No
Interested in:
*
Please Select
Complimentary Consultation Call Before the Evaluation
Schedule Evaluation ASAP
Complimentary Consultation Call Only
Submit
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