Appointment Request

To ensure we provide the best care for your child, appointments are scheduled directly with our team. Please provide the information below and a member of our team will reach out to you within two business days.

Appointment Request

Date(Required)

Parent / Guardian's Email Address(Required)

Contact Phone Number(Required)

Parent / Guardian's Name(Required)

Patient / Child's Name(Required)

Patient / Child's Date of Birth(Required)

Insurance Subscriber's Name (If Medicaid put Patient Name)

Insurance Subscriber's DOB (If Medicaid put Patient Date of Birth)

Picture of Insurance Card(Required)

Drop files here or

Max. file size: 1 GB, Max. files: 3.

Reason for Appointment(Required)

Articulation

Infant Feeding / Swallowing Disorders

Pediatric Feeding / Swallowing Disorders

Language

Motor Speech Disorders

Oral Motor Function Skills (Birth - age 4)

OroMyofunctional Therapy (over age 4)

Tethered Oral Tissues (Tongue Ties)

Other

Notes and Details

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Contact Us

10639 Meeting Street, Unit 101
Prospect, Kentucky 40059

Phone: 502-842-2428 (CHAT)
Fax: 502-842-2429
lori@chitchatchewky.com

Appointment Request

Contact Us

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