Online Registration Form

Client Registration Form

Name*

Age*

Gender*

Date of Birth*

Parent/Carer's Name*

Address*

Email Address*

Main Contact Number*

School

GP's Name

GP's Contact Number

Brief Description of Concerns

Please provide details of any previous speech pathology input

Medical History

Date of most recent hearing test

Glasses?

Date of most recent eye test (if known)

I have read and agreed to the terms and conditions set out in the Right Sounds Policy and Procedures documentation that were emailed to me

I consent for Right Sounds to collect and record my health information and share this with other providers only when necessary. I understand my privacy will be respected.

Fees:
All fees are payable on the day of consultation by credit card

Fill out our information form either online or download it and bring it with you to your first appointment.

PLEASE COMPLETE ONLINE FORM