Proudly Celebrating 60 Years
Chattanooga Skyline

Patient Form

Patient Form

To expedite the check-in process, please print the appropriate intake forms and mail or fax to the location below prior to your appointment. If you cannot send forms prior to your, please bring completed forms with you.

The Speech & Hearing Center
Attn: Scheduling Specialist
600 N. Holtzclaw Avenue, Suite 200
Chattanooga, TN 37404
Fax: 423.622.4843
emangrum@speechhearing.com 

Intake Forms – All Patients to Fill Out

Patient Information Form
Consent to Exchange Information Form
Consent to Comply With Federal HIPAA Act Form

Intake Forms – Audiology Patients

Hearing Case History Adult Form
Hearing Case History Child Form 

Intake Forms – Speech Pathology Patients

Speech Case History Adult Form
Speech Case History Child Form