Hearing Care Referral- Child | Advanced Hearing WA

GP/ENT Paedeatric Patient Referral Form

Patient Name(Required)

First Last

Date of birth(Required)

Sex

Male

Female

Parent/Guardian Details

First Last

Contact Phone Number(Required)

Patient Address

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

Please assess or provide (Children)(Required)

Visual response audiometry under 2.5 (*82318 & 82324)

Play audiometry hearing assessment over 2.5 (*82318 & 82324)

Oto-acoustic emission audiometry (*82332)

Other- please specify

Medicare codes apply to referrals from GP's, ENT's, Neurologists & Paedeatricians.

Relevant Clinical Information

Referring Doctors Details(Required)

Prefix First Last

Provider Number(Required)

Date

File

Drop files here or

Max. file size: 5 MB.

Please upload any information you believe may be relevant