REFERRING PHYSICIAN INFORMATION
Physician Name
*
Specialty
*
Select specialty
Neonatology
Pediatrics
Family Medicine
Pediatric ENT
ENT / Otolaryngology
Audiology
Pediatric Surgery
Genetics
Craniofacial / Plastic Surgery
Other
Practice / Institution
*
City, State
Physician Phone
*
Physician Email
Fax Number (for records / confirmation)
PATIENT INFORMATION
Patient First Name
*
Patient Last Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex at Birth
Select
Male
Female
Affected Side
*
Select
Right
Left
Bilateral
Microtia Grade (if known)
Select
Grade I - small but shaped ear
Grade II - partial ear structure
Grade III - small remnant / peanut-shaped
Grade IV - complete absence
Aural Atresia Present?
Unknown
Yes - confirmed
Yes - suspected
Canal is present
Partial stenosis
FAMILY CONTACT INFORMATION
Parent / Guardian Name
*
Parent Phone
*
Parent Email
Insurance (if known)
CLINICAL NOTES & COMPLETED WORKUP
Completed evaluations (please check all that apply)
ABR hearing evaluation completed
Audiology referral placed
BAHA softband fitting initiatied
Early Intervention referral placed
CT temporal bone obtained
Genetics referral placed
Referral urgency
*
Today
Urgent - within 1-2 weeks (bilateral newborn)
Routine - within 2-4 weeks
Clinical Notes / Reason For Referral
Submit Referral
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