Sonaris Request For Audiological Services

PHYSICIAN REFERRAL FORM
Please fill in all requested data below and press submit to complete.
If you have any questions, please contact us at info@sonaris.ca or 778.564.3277
Request For Audiological Services
Age of Client

Pediatric (0-19 Years)Adult (Over 19 Years)
Referral Date

MonthDayYear
Date
Personal Health Number
Full Name

First NameLast Name
Sex

MaleFemale
Address
Postal Code
Home Phone
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Cell Phone
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Work Phone
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Family Physician's Name *
Concerns, Tests and Procedures
Check All That Apply

Hearing ConcernSpeech Concern (Rule out hearing loss.)Ear TraumaPre/Post Surgery AudiogramSwim Molds/Hearing ProtectionDizziness/VertigoTinnitus (Ringing in the ears.)Behavior (e.g. aggression, tantrums, impulsiveness, difficulty with social skills)
Specialized Test/Procedures

Auditory ProcessingEvaluation Balance Function AssessmentCerumen Management (Patient must be at least 4 years old.)Hearing Aid Evaluation/FittingTinnitus Assessment
More Information (Concerns)
More Information (Specialized/Procedures)
Referral Source
Family DoctorENTPediatricianParent/GuardianPublic Health NurseSpeech-Language PathologistSchool/TeacherOther, Specify
Name*

First NameLast Name
Phone Number
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Fax
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Address
Postal Code
Signature (required)

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Request For Audiological Services