Referral Form Reach OutContact Us Today for Personalized Hearing Care Assistance Social Media Doctor's Corner Form Client's Name First Last Client's Date of Birth MM slash DD slash YYYY Client's TelephoneSymptoms (check all that apply) Hearing Loss (binaural) Hearing Loss (right) Hearing Loss (left) Dizziness/Loss of Balance Tinnitus Facial Tingling/Numbness Aural Pressure/Fullness Chronic Drainage Ear Infections Excessive Exposure to Noise History (check all that apply) Congenital Hearing Issue Family History of Hearing Loss Ototoxic Medications Chemo/Radiation Chronic Ear Infections Excessive Exposure to Noise Speech and Language Delay Assessments Required (check all that apply) Full Diagnostic Hearing Evaluation RCMP Hearing Evaluation Tympanometry Speech Assessment (WRS/SRT) Tinnitus Evaluation Cerumen Removal Custom Ear Defenders Custom Sleep Plugs Custom Swim Plugs Check of Current Hearing Aids Hearing Aid Consultation Assistive Listening Device Consultation Referring Physician First Last Clinic NamePhysician TelephonePhysician Fax Join Our CommunityTake Charge of Your Hearing TodayContact us to book your appointment and explore the best hearing solutions designed specifically for you.Book a Consultation
