Please download and review the following information before filling out the form belowWelcome to SpeechcenterNotice of Privacy Practices (Optional) Only download the PDF form below if you wish to fill out the consent form manually. Download PDF Consent form (Optional) Fill out the form in Spanish español Consent Form * I agree with the Welcome Letter and Notice of Privacy PracticesGeneral Patient InformationSection Patient Last Name Patient First Name Patient Middle Name Patient DOB (mm/dd/yyyy)Patient Street Address Patient Street Address Patient Street Address Patient Street Address City City State/Province (Please Abbreviate) Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province (Please Abbreviate) Zip/Postal Zip/PostalPatient Mailing Address (if different from address above) Patient Mailing Address (if different from address above) Patient Mailing Address (if different from address above) Patient Mailing Address (if different from address above) City City State/Province (Please Abbreviate) Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province (Please Abbreviate) Zip/Postal Zip/Postal Patient Home Phone Number Patient Cell Phone Number Patient Work Phone Number Patient Gender Male FemalePatient Employment Status Employed Full-Time Student Part-Time StudentPatient Marital Status Single Married Other Patient School (if school aged) Social Security Number Patient Email Address If you are human, leave this field blank. Next