Referral for
Hearing Services
bloom™ hearing specialists		

PATIENT DETAILS

First name		Last name		Phone number	

<PtFirstName>		
<PtSurname>		<PtPhoneMob>  <PtPhoneH>	
Date of Birth		Pension Number		Medicare Number	

<PtDoB>		
<PtPensionNo>		
<PtMCNo>	

PLEASE CONDUCT THE FOLLOWING

		 Hearing Assessment (patients over 4 years of age)	
			
		    Full Diagnostic  (Air and Bone Conduction, Tympanometry with Acoustic Reflexes if warranted, Speech discrimination)	
			
		    Air Conduction only	
			
		   Tympanometry only	

	  Custom made Plugs 	
		
	  Wax removal via microsuction and/or curettage	
		
	  Tinnitus Management	
		
	  Hearing Loss Solutions	
		
	  Other (please specify in notes below)	

CLINIC NOTES

	

DOCTOR DETAILS

Date:  <TodaysDate>	

Name: <DrName>	

Clinic Name: <Practice>	

Provider number: <DrProviderNo>	

	<Practice>

<DrAddress>

Ph:<DrPhone>

Fax: <DrFax>

Email: <DrEmail>	

Accredited to provide free hearing care services to Pensioners & Veteran Affairs clients under the OHS program
ABN: 91 087 971 051