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Click ‘Get Form’ to open the AUDIOLOGY REFERRAL FORM in the editor.
Begin by filling out Section 1: Patient Information. Enter the patient's last name, first name, date of birth, and contact details including home and cell/work phone numbers. Ensure all fields are completed accurately to avoid delays.
In Section 2: Reason for Referral, check all relevant boxes that apply to the patient's condition. If necessary, provide additional comments in the designated area to give more context about the referral.
Complete Section 3: Referral Source by selecting the appropriate provider type and entering their contact information. Don’t forget to include your signature at the end of this section.
Once all sections are filled out, review your entries for completeness. Incomplete forms will be returned, so double-check each field before submission.
Finally, fax the completed form to 613-738-4222 as instructed on the document.
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Common Red Flags and Referral Guidelines Timeline Asymmetrical or Unilateral Hearing Loss - Age related hearing loss should be symmetrical. Sudden hearing loss (over 72 hours or less) within the past 30 days is considered a medical emergency.
What are the red flags for audiology referral?
Unexplained unilateral or asymmetric hearing loss. Persistent unexplained unilateral or asymmetric tinnitus or vertigo/dizziness. Aural fullness. Facial paralysis, paresis or weakness.
Why has my child been referred to audiology?
Children will be referred to audiology for the following reasons: Hearing concerns such as mishearing speech/instructions or favouring devices like tablets or TV to be louder. As a follow up to the newborn hearing screening program. As a follow up to the school entry hearing screening program.
What is the 1 3 6 rule in audiology?
Recommended Early Hearing Detection and Intervention (EHDI) benchmarks include screening for hearing loss before 1 month of age, diagnostic evaluation before 3 months of age, and enrollment in early intervention before 6 months of age, known as the 1-3-6 benchmarks.
When to refer to an audiologist?
It is recommended anyone with concern about their hearing get evaluated by a licensed audiologist as the first step, even if they intend to purchase an OTC hearing aid. experiencing greater than a perceived mild to moderate hearing loss.
Related Searches
CHEO Audiology ClinicCHEO cochlear implant ProgramHearing test for kids OttawaAudiology for kidsCHEO clinic BChild hearing test near me
People also ask
What are the red flags for ear exams?
A distinctly red, yellow, or cloudy tympanic membrane. Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks and an air-fluid level behind the tympanic membrane (indicates a middle ear effusion). Perforation of the tympanic membrane and/or discharge in the external auditory canal.
When to refer to ENT audiology?
If you are experiencing serious ear disorders or you have symptoms that are also affecting other areas of your nose and throat, you may be referred to an ENT. Audiologists are limited to treatment such as ear infections, hearing loss, tinnitus, impacted earwax or balance issues.
Can you self refer to audiology?
Self referral is a direct route to Audiology for hearing assessment and provision of National Health Service hearing aids. Using self referral means that you do not have to see any other health care provider (including your family Doctor or practice nurse) first.
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