Referring Doctor’s Details (stamp here)	
Doc Name	
Provider Number	

Address	

Referral Form

Referral Date	/	/	Signature	
Results requested by	Post	
	Fax	
	Email	
Patient’s details (Please print)		
Name	DOB	
Patient best contact number		
Patient address		
Does patient hold a Centrelink pension card or DVA gold card?	Yes	No	
Card number		
Medicare number	Patient Ref	

Standard Consultation	
Audiology service(s) required for patient to receive a Medicare rebate	
Comprehensive assessment (air conduction, bone conduction, speech discrimination, Tympanometry, reflexes, oto-acoustic emissions)	Standard assessment (air conduction, bone conduction, speech discrimination, Tympanometry, reflexes)	
Basic assessments	
Air conduction, bone conduction	Air conduction, speech discrimination	
Tympanometry, reflexes	Oto-acoustic emissions	

Consultations not covered by Medicare	
Wax Management	
Auditory Processing Disorder Assessment	
Hearing Protection	
Hearing Device Discussion	
Tinnitus Consultation	

PATIENT INSTRUCTIONS

To book your appointment visit candohearing.com.au and book online or call 8100 8209

Please bring this referral form, your Medicare card and your pension/health care card Medicare rebates are available when the consultation meets criteria.
Other non-funded indications will attract a fee that will be advised at the time of booking.

Can:Do Hearing is a social enterprise supporting SA’s oldest charity, Can:Do 4Kids