New Patient Inquiry
Hello! Thanks for connecting with us! 

We are not currently accepting new patients for speech, feeding, or myofunctional therapy for older children and adults. 

If you would like to join our priority list, please complete this form. If you would like to speak to someone regarding services, please use the link below to schedule a call. You will not receive a call from us until an opening is available. 


Our office hours are by appointment only. 

555 S. Perryville Road 
Suite 021
Rockford, IL 61108
815-290-0829
frontdesk@eatsandspeaks.com

****PLEASE DOUBLE CHECK TO MAKE SURE YOU RECEIVED A COPY OF THIS FORM IN YOUR INBOX TO ENSURE IT HAS BEEN SUBMITTED CORRECTLY. THANK YOU! 
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Email *
Patient First and Last Name *
Parent First and Last Name *
Patient Birthdate *
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Address (Street) *
City, State, Zip Code *
Phone Number (if this is not provided, we will not be able to connect with you via phone)
Email *
Type of Insurance (If you have insurance) *
Please list the concerns you have for yourself or your child. *
Please share what you hope to accomplish in therapy. *
What days and time frames are available for therapy sessions? *
What is the best day and time to reach you to get set up? *
How did you hear about us? *
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I completed this form via *
This form was easy to access and complete. *
Do you agree to receive text messages from Eats and Speaks sent from 815-290-0829? Message frequency varies and may include appointment reminders, replying to patient questions and inquiries. Message and data rates may apply. Reply STOP at any time to end or unsubscribe. For assistance, reply HELP or contact support at 815-290-0829. 

See our privacy policy linked below to see how we handle your data. 

https://www.eatsandspeaks.com/privacy
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