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External Professional VA Intake

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External Professional VA Intake

Check Your Client’s Insurance Eligibility

Thanks for considering a Lingraphica AAC device for your client. To start a trial, please complete this form. It only takes a few minutes.

Need help or have questions? Call us now at 866-570-8775

Speech-Language Pathologist Information
Hidden
Sales Channel*
Have you previously conducted a Lingraphica device trial?*
- Yes
- No
Name of Speech Therapist*
First Last
Email*
Enter Email Confirm Email
Do you use your mobile phone, work phone, or both?*
- Mobile Phone
- Work Phone
- Both
Mobile Phone Number*
Work Phone Number*
Extension
How would you like us to contact you?*
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Have you participated in any of the following with Lingraphica? (Check all that apply)*
- Online CEU Course
- Live Webinar
- On-Site Patient Consultation
- On-Site In-Service
- Lingraphica Certification Program
- None
Who conducted the in-service, webinar or on-site visit?
Are you interested in scheduling a virtual in-service with a Lingraphica representative?*
- Yes
- No
Requested Trial Device Information
Which Lingraphica Communication Device would you like to trial?*
All of Lingraphica's communication devices have the same software. The only difference is size. To learn more about our devices, visit https://lingraphica.com/aac-devices/
Which accessories would you like to trial? (Choose all that apply)*
In addition to the standard case and stylus, please select up to 2 (two) accessories from the list below. Select None if you do not wish to trial any accessories. To learn more about accessories visit https://lingraphica.com/aac-devices/aac-device-accessories.
- Standard Mouse (Wireless)
- Joystick
- Stylus Tether
- Wireless Keyboard
- EZ Eyes Keyboard
- Ball Stylus
- Extended Stylus
- T Stylus
- Weighted Stylus
- Flexible Stylus with Strap
- Long Flexible Stylus
- Rugged Case (MiniTalk only)
- None (all devices come with a standard case and stylus)
Shipping Information for Trial Device
Please note: Trial devices must be sent to the speech-language pathologist. A signature is required for delivery of the trial device.
Which VA Medical Center do you work for?*
VA Medical Center Name*
VA Medical Center Street Address*
VA Medical Center Street Address 2
VA Medical Center City*
VA Medical Center State*
VA Medical Center Zip Code*
VA Medical Center Phone*
Additional Information for Shipping
Use this space to alert Lingraphica to any changes needed to the address of your VA facility, add a specific name or department, office hours, etc.
Patient Information
Patient's First Name (or Initial)*
Patient's Last Name*
Date of Birth
Gender
Pronoun
- She/Her
- He/Him
- They/Them
Phone Number
How would you like us to contact the patient?*
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Does your patient have their own email address?*
Email
Enter Email Confirm Email
Which language does the patient prefer to use when communicating with the Lingraphica team?*
- English
- Spanish
- Other
Please describe your patient's monolingualism or bilingualism*
Medical Diagnosis*
Please enter the diagnosis*
Caregiver/Emergency Contact Information
Name of spouse, caregiver, or support person
Phone Number of spouse, caregiver, or support person
Email of spouse, caregiver, or support person
Enter Email Confirm Email
Relationship to the Patient
- Spouse
- Parent
- Child
May we reach out to the caregiver/communication partner?*
- Yes
- No
- Not yet

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