Tinnitus Relief Australia - GP Referral
Please complete the below referral form for patients experiencing tinnitus-related distress. Our team will contact the patient directly and provide clinical updates throughout treatment.
Referring GP Details
GP Full Name
*
Practice Name or Organisation
*
Practice Email
*
Patient Details
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Patient Phone Number
*
Patient Email
*
Patient Address
Street Address
Street Address Line 2
City
State
Postcode
State
Please Select
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Is your patient a veteran?
*
Yes
No
Do they hold a DVA card?
Please Select
Gold Card
White Card
DVA Card Number
Clinical Summary
Has the patient’s tinnitus impacted any of the following?
Sleep disturbance
Concentration / cognition
Mental health / emotional wellbeing
Anxiety or stress
Work / daily functioning
Social engagement / relationships
Hearing / communication difficulties
Quality of life
Duration of tinnitus
<3 months
3–12 months
1–5 years
5+ years
Clinical History & Additional Information
Please include any relevant clinical history, known or suspected cause, contributing factors, prior treatment, hearing history, medications, or other information relevant to this referral.
Supporting Documents. Upload any relevant clinical information (optional)
Browse Files
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(e.g. Referral letter, audiogram, ENT report, relevant medical history and for veteran patients, please include Signed D904 Referral Form.)
Cancel
of
Declaration
*
By ticking this box, I confirm this referral is clinically appropriate and that the patient has provided consent to be referred to Tinnitus Relief Australia.
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