Audiologist Application 7.1.2025

APPLICATON

Audiologist Section
Audiologist Information
Today's Date

MonthDayYear
Date
Name
Email Address
example@example.com
Phone Number
PATIENT INFORMATION
Name
DOB
Parent/Guardian Name
HEARING HISTORY
Age of Identification
Type of Hearing Loss

Left Type NoneRight Type NoneLeft SensorineuralRight SensorineuralLeft ConductiveRight ConductiveLeft MixedRight MixedLeft Auditory NeuropathyRight Auditory Neuropathy
Degree of Hearing Loss

Left Degree NoneRight Degree NoneLeft MildRight MildLeft ModerateRight ModerateLeft SevereRight SevereLeft ProfoundRight Profound
Newborn Hearing Screening

NHS PassNHS FailNHS Unknown
HEARING AID REQUEST

Unilateral (1) Hearing AidBilateral (2) Hearing Aids
Requested make, model, power level & battery size
Left Device
Right Device
The following documents can be uploaded by the parent or the audiologist. If you are including any of the below documentation, please check the appropriate boxes.
Medical clearance for hearing aids dated within 6 months of application date signedAudiogram completed and dated within 6 months of application date.Birth certificate for children not yet in kindergarten or proof of school enrollmentThree consecutive pay stubs for all working adults in the household. If self-employed,
File Upload

Cancelof
Participating Audiologist Signature
*I affirm that I have investigated other possible sources of funding for this patient.

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APPLICATON