Medical Clearance 7.1.2025

Patient Name
Patient Date of Birth

MonthDayYear
Date
The above patient has been medically evaluated and is considered a candidate for a hearing aid(s The hearing loss is not due to a temporary, correctable physical condition. There are no contraindications to hearing aid candidacy.

* This form MUST be signed by an MD or DO - NP or PA signature not accepted.
Physician Signature

Clear
Date

MonthDayYear
Date
Physician Name (Please print)
Info@HearIndiana.org 317-828-02114740 Kingsway Drive, Suite 33Indianapolis, IN 462015
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