Jervis Bay Hearing Centre
Call us today!
Vincentia | 02 4441 8886
​Ulladulla | 02 4455 6000
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Contact Us
Audiology Referral for Medical Professionals
Please complete the form below to refer patient for audiology services
Patient Details
*
Indicates required field
Patient Name
*
Phone
*
DOB (DD/MM/YYYY)
*
Address 1
*
Address 2
*
City
*
State
*
Funding Options for Diagnostic Audiology
Please select from the list below
*
Office of Hearing Services (OHS) for Pensioners & Veterans
Department of Veterans' Affairs (DVA)
Enhanced Primary Care (EPC)
National Disability Insurance Scheme (NDIS)
Privately Funded/Health Insurance
Unknown (refer for free hearing screening)
Please provide any details of funding available to patient
If your patient is a
Pensioner or Veteran
, please complete the medical certificate to enable them to join the Commonwealth Government OHS Voucher program.
C
lick here to download the PDF
When completed, fax to the nearest hearing centre:
Vincentia
Fax
4441 7889
Ulladulla
Fax 4455 6008
Other Funding
*
Details for Patient Referral
We Also Offer Free Hearing Checks for Adults
Medical Diagnostic Audiology
*
Asymmetry
Ear Infection
Hearing Loss
Sudden Hearing Loss
Hypercusis
Vertigo
Tinnitus & Tinnitus Solutions
Cochlear Implant Candidacy
Bone Anchored Hearing Aid (BAHA)
Industrial/Work Injury/Workers Compensation
Who fall into these categories:
*
Over 65 years of age
Unsure about their hearing
Reluctant to get hearing treatment
Never had a hearing check previously
And have no medical issues (ie. Tinnitus, Vertigo, etc)
Full Assessment and Evaluation for Communication Pathway
*
Hearing Loss Impacts on Communication
Patient Requires Repeats
Patient Requires Loud Speech
Patient Requires Visual Cues
Reports Difficulty Hearing with Background Noise
Comments
*
Please provide any further information
Doctor's Details
Referring GP Name
*
First
Last
Phone Number
*
Medical Practice
*
Fax Number
*
Submit
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