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    Toronto Hearing Services Referral 2020

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    Alena Yevs
    The document is a referral form from a doctor to Toronto Hearing Services requesting a diagnostic hearing test for a patient. It contains fields for selecting the reason for referral such as possible hearing loss or tinnitus. It also includes sections for the patient's name, date of birth, health card number, and contact information, as well as the referring doctor's name, billing number, contact details, and an area for remarks.

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    Toronto Hearing Services Referral 2020

    Uploaded by

    Alena Yevs
    10 views1 page
    The document is a referral form from a doctor to Toronto Hearing Services requesting a diagnostic hearing test for a patient. It contains fields for selecting the reason for referral such as possible hearing loss or tinnitus. It also includes sections for the patient's name, date of birth, health card number, and contact information, as well as the referring doctor's name, billing number, contact details, and an area for remarks.

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    Toronto-Hearing-Services-Referral-2020

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    The document is a referral form from a doctor to Toronto Hearing Services requesting a diagnostic hearing test for a patient. It contains fields for selecting the reason for referral such as possible hearing loss or tinnitus. It also includes sections for the patient's name, date of birth, health card number, and contact information, as well as the referring doctor's name, billing number, contact details, and an area for remarks.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    10 views1 page

    Toronto Hearing Services Referral 2020

    Uploaded by

    Alena Yevs
    The document is a referral form from a doctor to Toronto Hearing Services requesting a diagnostic hearing test for a patient. It contains fields for selecting the reason for referral such as possible hearing loss or tinnitus. It also includes sections for the patient's name, date of birth, health card number, and contact information, as well as the referring doctor's name, billing number, contact details, and an area for remarks.

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    DIAGNOSTIC HEARING TEST (DHT) REQUEST/REFERRAL

    Jerry J. Halik M.D., F.R.C.S. (C). Otolaryngology (E.N.T.)

    ☐ Diagnostic Hearing Test (DHT) ☐ Sudden Hearing Loss—URGENT

    TORONTO HEARING SERVICES


    WWW.TORONTOHEARINGSERVICES.COM
    THE AUDIOLOGY CENTRE #340-1333 SHEPPARD AVE. E., NORTH YORK, ON M2J 1V1
    AudiologyCentre@TheTorontoHearingServices.com T: 416-498-4151 F: 416-498-1589

    MARKHAM STOUFFVILLE HEARING SERVICES #203-377 CHURCH ST., MARKHAM, ON L6B 1A1
    MarkhamStouffville@TheTorontoHearingServices.com T: 905-471-4327 F: 905-471-4338

    WEST END HEARING SERVICES #711-1243 ISLINGTON AVE., ETOBICOKE, ON M8X 1Y9
    WestEnd@TheTorontoHearingServices.com T: 416-233-8581 F: 416-233-4390

    REASON FOR REFERRAL:

    ☐ POSSIBLE HEARING LOSS ☐ HEARING AID EVALUATION ☐ TINNITUS

    ☐ AUDITORY PROCESSING DISORDER (APD) ASSESSMENT ☐ CUSTOM EAR PLUGS (I.E. SWIM, MUSICIANS, ETC.)

    ☐ OTHER: ________________________________________________________________________________________________

    PATIENT INFORMATION

    NAME:

    DATE OF BIRTH: HEALTH CARD NUMBER:

    TELEPHONE:

    EMAIL:

    REFERRING DOCTOR

    NAME: BILLING #:

    TELEPHONE: FAX:

    EMAIL:

    REMARKS/COMMENTS:

    DATE: DOCTOR’S SIGNATURE:

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