Online Referral – Implants

Patient's name*
Date of birth*
Date of referral*
DD slash MM slash YYYY
Patients email*
Patients phone*
Preferred clinic location
Does the patient require
- A Hearing implant audiological assessment?
- A Hybrid / Vibrant soundbridge assessment?
- Other
Other - please detail:
Has the patient had a maximum retune of their hearing aids?
- Yes
- No
Would you like Northside Audiology to retune their current hearing aids?
- Yes
- No
Does the patient have a CT and/or MRI of their inner ears?
- Yes
- No
BAHA assessment
- Single-sided deafness (with normal contralateral side)
- Conductive HL
- Mixed HL (with normal contralateral side)
Referring doctor / Audiologist*
Provider number*
Doctor's telephone No.*
Doctor's fax No.
Doctor's email address
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