Forms3To minimize the waiting period as much as possible, please print out the forms and bring a completed copy with you to your appointment.
Please fill out all forms that are applicable to you or your child.

Forms can be faxed to (863) 682-1348 or mailed to 3020 Lakeland Highlands Road, Lakeland, FL 33803

Required For All Patients

   Notice of Privacy Practices

Adult Patients

   Hearing Health History     Speech-Language Health History

Pediatric Patients

   Hearing Health History     Speech-Language Health History      Speech-Language Health History (Español)

Existing Patients

   Medical Release Form      Release of Medical Records      Media Permission      Patient Testimonials

 

referrals

Physician referrals to the Center are quick and easy.

To refer a patient for a speech or language consultation
Please call Beatrice Lopez at 863-686-3189, or email blopez@cfshc.org.

 

To refer a patient for a hearing consultation, diagnosis or treatment (including hearing aids)

Please call Brenda Blalock at 863-686-3189, or email bblalock@cfshc.org