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Online Referral Form

Client's Name:

Date of Birth:

Telephone:

I wish to refer my patient to:

	North Hill Clinic, Calgary (view address and map)		Sunpark Clinic, Calgary (view address and map)
	Crowfoot Clinic, Calgary (view address and map)		Okotoks Clinic, Alberta (view address and map)
	Creston Clinic, BC (view address and map)		Cranbrook Clinic, BC (view address and map)

SYMPTOMS		HISTORY
	Hearing Loss Right Ear Left Ear Both Ears		Family History of Hearing Loss
	Dizziness / Loss of Balance		Ototoxic Medication / Chemo / Radiation
	Tinnitus		Excessive Noise Exposure
	Facial numbness		Chronic Ear Infections
	Middle Ear / Eustachian Tube Dysfunction		Speech & Language Delay
	Other:		Other:

ASSESSMENTS REQUIRED

Hearing Loss
Hearing Levels Tympanometry
Speech Testing (SRT & WDS)

Custom Ear Plugs for Noise
Custom Swim Plugs / Sleep Molds
Hearing Aid(s) Evaluation & Order

Tinnitus Evaluation

Check Current Hearing Aid(s)

Tinnitus Masker(s) Evaluation & Order