Gp/ENT Adult Patient Referral Form

Patient Name(Required)

First Last

Contact Phone Number(Required)

Date of birth

MM slash DD slash YYYY

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please assess or provide (Adults)(Required)

Hearing aid trial (please indicate if there are contraindications)

Full audiological audiogram (*82318 & 82324)

Tympanometry and acoustic reflexes only (*82324)

Tinnitus assessment & management (*82318 & 82324)

Pre-employment / work cover assessment

Custom made ear plugs

Other- please specify

Medicare codes apply to referrals from specialists (Ear, Nose & Throat Surgeon, Neurologist etc)

Relevant Clinical Information

Are there any contra-indications to a hearing aid fitting?? (Check box)

Yes (please provide details in the box)

Referring Doctors Details

Prefix First Last

Provider Number(Required)

Date

MM slash DD slash YYYY

GP CONSENT(Required)

Referring doctor to tick

By ticking this box, you consent to your patient being contacted by Advanced Hearing WA to book their audiological assessment as indicated on this form.

File

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Max. file size: 5 MB.

Please upload any information you believe may be relevant

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Find us at one of our many locations across the South West or phone us on 08 9751 1899

OUR CLINIC IS CURRENTLY OPEN FROM

9AM-12PM MONDAY TO FRIDAY

WE ARE AVAILABLE FOR:

CONTACTLESS REMOTE HEARING AID APPOINTMENTS

ALL BATTERY & FILTER PURCHASES

URGENT APPOINTMENTS

PICK UP AND DROP OFF SERVICE AVAILABLE

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Appointment Enquiry

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Phone*
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Preferred Clinic
- Busselton
- Vasse
- Dunsborough
- Margaret River
- Augusta
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