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admin@newcastlehearingcentre.com.au
Lvl 1, 218 Pacific Hwy, Charlestown NSW 2290 **entry via Pearson Street Mall**
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Allied Health Referral
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Allied Health Referral
Online Referral Recommendation
This form is for allied health and related professions.
Date of Recommendation
DD slash MM slash YYYY
Patient Name
First
Last
Date of Birth
DD slash MM slash YYYY
Sex at Birth
Male
Female
Patient Parent/Guardian Name
Parent/Guardian Phone
Parent/Guardian Address
Parent/Guardian Email
Reason For Referral
Delayed Speech and Language Development
Poor Speech Clarity or Unusual Speech Patterns
Frequent Need for Repetition
History of Ear Infections or Middle Ear Fluid
Inconsistent Response to Sounds or Difficulty Following Directions
Other
Other Reason
Assessment Requested
BOA- from birth (if SWISH has been performed)
VROA - from 8 months
Play Audiometry - 2.5-6 years
Diagnostic Audiology - from 6 years
Custom earplugs
Person Requesting Referral
Referrer Email
Referrer Phone
Additional Comments
I understand Newcastle Hearing Centre for Children is a private fee clinic. A GP referral is not required, however a Medicare rebate is applicable with a referral from a medical practitioner.
(Required)
Yes
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