Referral for
Hearing Services
bloom™ hearing specialists		

PATIENT DETAILS

First name		Last name		Phone number	

<<Patient Demographics:First Name>>		
<<Patient Demographics:Surname>>		<<Patient Demographics:Phone (Mobile)>>  <<Patient Demographics:Phone (Home)>>	
Date of Birth		Pension Number		Medicare Number	

<<Patient Demographics:DOB>>		
<<Patient Demographics:Pension Number>>		
<<Patient Demographics:Medicare Number>>	

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:  <<Miscellaneous:Date (short)>>	

Name: <<Doctor:Name>>	

Clinic Name: <<Practice/Location:Name>>	

Provider number: <<Doctor:Provider Number>>	

	<<Practice/Location:Name>>

<<Doctor:Full Address>>

Ph:<<Doctor:Phone>>

Fax: <<Doctor:Fax>>

Email: <<Doctor:E-mail>>	

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