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102-8644 120th St. Surrey, BC
306-5050 Kingsway, Burnaby, BC

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Physician Referral

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PHYSICIAN REFERRAL FORM

Please fill in all requested data below and press submit to complete.
If you have any questions, please contact us at info@sonaris.ca or 778.564.3277

CLICK HERE TO DOWNLOAD THE PHYSICIAN REFERRAL FORM PDF

Physician Referral Form

REQUEST FOR AUDIOLOGICAL SERVICES

Age of Client

PEDIATRIC (0-19 Years)

Adult (Over 19 Years)

Referral Date

Personal Health Number

Name(required)

Date of Birth(required)

Sex(required)

Male

Female

Address

Postal Code

Home Phone(required)

Cell Phone

Work Phone

Family Physician’s Name(required)

Concerns, Tests and Procedures

CHECK ALL THAT APPLY

Hearing Concern

Speech Concern (Rule out hearing loss.)

Ear Trauma

Pre/Post Surgery Audiogram

Swim Molds/Hearing Protection

Dizziness/Vertigo

Tinnitus (Ringing in the ears.)

Behavior (e.g. aggression, tantrums, impulsiveness, difficulty with social skills)

OtherOther

SPECIALIZED TESTS/PROCEDURES

Auditory Processing Evaluation

Balance Function Assessment

Cerumen Management (Patient must be at least 4 years old.)

Hearing Aid Evaluation/Fitting

Tinnitus Assessment

More Information

More Information (Specialized Tests/Procedures)

Referral Source

Family Doctor

ENT

Pediatrician

Parent/Guardian

Referral Source

Public Health Nurse

Speech-Language Pathologist

School/Teacher

Other, SpecifyOther, Specify

Name(required)

Phone(required)

Fax

Address

Postal Code

Signature(required)

Clear

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