Request an appointment

Patient Name *

First Name

Last Name

Patient DOB *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment *

Private Pay (enter N/A in fields below)

Insurance

Insurance Subscriber's Name

First Name

Last Name

Insurance Subscriber's DOB

MM

DD

YYYY

Parent Name *

First Name

Last Name

Parent Phone *

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###

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Pediatrician/PCP Name *

First Name

Last Name

Office Location

Please indicate which office location(s) you would like to visit.

Providence, RI

Pawtucket, RI

East Greenwich, RI

Lincoln, RI

Hopkinton, MA

Shrewsbury, MA

Please select the service(s) you are seeking: *

Speech/Language

Orofacial Myology

Occupational Therapy

Nutrition

Floortime

Feeding

Voice/Parkinson's Disease

Respiratory Therapy

Tongue Tie

Craniosacral Fascial Therapy - CFT (Private Pay ONLY)

Student

My child is a Wheeler/Hamilton student.

Yes

No