New Patients

We are accepting new patients. Please use the following forms. Print, fill out and bring them with you to make your first visit easier.

To protect your confidentiality, please do not email completed forms.


THERAPIST-PATIENT SERVICES AGREEMENT updated June 9 2017 (PDF)

Agreement Acknowledgement (PDF)

CHILD HISTORY FORM (PDF)

Consent for Use and Disclosure of Protected Health Information (PDF)

Health Information Release (PDF)


For more information, visit our Contact page or call us at (321) 751-1443,

Diana G. Masker & Associates
Pediatric Speech Language Therapy

3040 N. Wickham Rd., Suite 4
Melbourne, FL 32935

(321) 751-1443 tel
(321) 751-1448 fax

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Diana G. Masker & Associates