REFERRAL FOR HEARING REVIEW

To: Steven Hooper HEARING - CARE
MACAud QP (OHS) No: 2505001W Prov No: 020614F
Audiometric Assessments & Hearing Device Clinic - Statewide Service

FREE CALL: 1800 201 509 for Appointments

Dear Steven,

Patient name: <<Patient Demographics:Full Name>>		Date of birth: <<Patient Demographics:DOB>>

Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>

Phone: (h) <<Patient Demographics:Phone (Home)>>   (m) <<Patient Demographics:Phone (Mobile)>>   (w) <<Patient Demographics:Phone (Work)>>

Reason for referral:

Please provide:	[  ] A complete hearing assessment/review
			[  ] Air conduction only
			[  ] Tympanometry
			[  ] Hear saver ear plugs
			[  ] Other

I would like to be informed of the outcome:		YES [  ] / NO [  ]
________________________________________________________________________________

MEDICAL PRACTITIONER CERTIFICATION
The Australian Government Hearing Services Program provides eligible people with access to hearing services. Services may include hearing assessments, information and support, hearing devices and fittings, and contributions to the maintenance and repair of hearing devices.

Are there contraindications to having a hearing test / the fitting of a hearing device if needed?

[  ] YES (may still be eligible for other hearing services)
[  ] NO

Referred by: <<Doctor:Name>> - Provider Number: <<Doctor:Provider Number>>

Practice Address: <<Doctor:Address>>, <<Doctor:City>>, <<Doctor:State>>, <<Doctor:Postcode>>

Phone: <<Doctor:Phone>>   Fax: <<Doctor:Fax>>   Email: <<Doctor:E-mail>>

Date: <<Miscellaneous:Date>>

I acknowledge that Steven Hooper Hearing Care may collect, use, store or disclose any personal information I provide to the patient (including my GP Provider No:) for the purpose of applying for a Voucher to the Office of Hearing Services on the patient's behalf.

Medical Practitioner's Signature:________________________________________________