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Physician Referral Form

To refer a patient for an evaluation and treatment for swallowing, cognition, voice, or speech-language, please fill out the referral form below and fax it to 716-302-5357 or email it to, along with the patient’s insurance card and medical history. SPS of WNY will then contact the patient directly to arrange an appointment.


To order a swallow study (fiberoptic endoscopic evaluation of swallowing), please check the option labeled ‘Endoscopy’; on the referral form.

SPS of WNY will send the referring physician a copy of the patient’s evaluation (including images from instrumental assessments) and plan of care, along with periodic updates about the patient’s progress.


Feel free to call SPS of WNY at 716-791-7573 with any questions. 

© Speech Pathology Services of WNY

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