AUDIOLOGY REFERRAL FORM

Barking & Dagenham, Havering and Redbridge

Please note – we are unable to accept referrals for patients under 18 years of age

PATIENT	REFERRER
NHS Number	NHS Number	Name	Registered GP
Forename	Forenames	GMC/HPC/NMC No
Surname	Surname	Address	Practice Address Stacked
Address	Patient Address Stacked
Date of Birth	DOB	Referring CCG Code
Telephone (Home)	Home Telephone	Referring Practice Code
Telephone (Work)	Work Telephone	Telephone No.

(for urgent clinical findings)	Practice Main Telephone
Telephone (Mobile)	Mobile Telephone	Fax No.
E-mail Address	NHS.net mail only
Gender	Sex	If interpreter required, language:
Physical/Communication difficulties (specify if any):

Wheelchair user? Yes
The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.
Ethnicity: Ethnic Origin
PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS

Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and results.

Date of referral System Date
Please can you ensure that the patients ears are clear of wax if possible before their appointment.

Has the patient previously been fitted with a hearing aid?

Date of last hearing assessment

If previous hearing assessment in last four months, please attach results.

Yes No

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Please post, fax or e-mail this form to the InHealth Patient Referral Centre:

Sandbrook House, Sandbrook Way, Rochdale OL11 1RY

Tel: 0333 202 0297 Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net

www.inhealthgroup.com

Version: EMIS Dec 2014

INHEALTH

Caroline

2014-12-08

InHealth Ltd