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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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