Online Booking Request Form

T 03 9028 4879 | M 0423 374 684 | E contact@archesaudiology.com.au
INDEPENDENT AUDIOLOGY

Specialising in APD | HEARING AIDS | WAX REMOVAL| MICROSUCTION
PLEASE SELECT CLINIC LOCATION REQUIRED

'ACE YOUR HEARING' - 2-session Program WaitlistMULGRAVE - Sia Medical Centre, Suite 25, Level 1/372 Wellington Road, MulgraveCHURCHILL - Churchill Family Practice, Shop 4-5, 10 West Place, ChurchillHOME VISIT - within 15km of Mulgrave. NB: travel fees apply
PATIENT Surname
PATIENT Given Name
PATIENT Title

DrMrMrsMsMxMasterMissOther
Date of Birth

DayMonthYear
Language Spoken
INTERPRETER REQUIRED

YESNO
PATIENT CONTACT NUMBER
PATIENT EMAIL ADDRESS
Best Contact Person Name and Number (if applicable)
To ensure we allocate the correct amount of time and the right equipment for your visit, please select your assessment type below.

Medicare Rebates: To receive a Medicare rebate, you must have a valid referral from your GP or accepted medical practitioner before your appointment. For specialised audiological services such as wax removal/microsuction, tinnitus sessions or APD services, please ask your doctor for a GP Chronic Condition Management (GPCCM).HSP (Pensioners/Veterans): If you have a pension card or Department of Veteran Affairs card, or are a dependent listed on either card, you may be eligible through the Hearing Services Program. To check your eligibility prior to your appointment, please visit the Hearing Services Program website here http://bit.ly/3NK70Tz.Private Health Insurance: You may be able to claim through your Private Health Insurance extras depending on your level of cover.Private Patients: No referral is required.
REFERRAL TYPE

Self referralGP referralENT referralPaediatrician referralAudiologist referralMCHN referralFamily / friend
REASON/S FOR REFERRAL
(OPTIONAL )

Sudden Hearing LossLongstanding Hearing LossTinnitus concernsDizziness/VertigoWax occlusion / foreign bodyAuditory Processing DisorderHearing Aid Assessment and FittingNDIS participantHearing Services Program eligible (eg. Pensioners, DVA, ADF, Disability Employment Service referral)Ear Protection / Custom Ear Plugs (swim plugs, sleep plugs, musician earplugs)
TYPE OF ASSESSMENT REQUIRED

URGENT Assessment (within 48 hours of first symptoms appearing)Wax removal / MicrosuctionAdult Audiological AssessmentPaediatric Assessment (approx 3 years+)Auditory Processing Disorder - EvaluationAuditory Processing Disorder - Therapy and TechnologyHearing Services Program servicesPolice / Pilot / Pre-Employment Audiological AssessmentHearing Aid Discussion and AssessmentOther
FOR MEDICAL / MCHN / HEALTH PROFESSIONAL REFERRERS TO COMPLETE
Name
Clinic Address
Best Contact Phone/Email
Medicare Provider Number
*Fully subsidised services may be available for people eligible for Hearing Services Program.

**Medicare rebates are available with a GP referral per appointment. Patients are to claim either from Medicare or Private Health Insurer as applicable.
Additional Information
Date

MonthDayYear
Date
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INDEPENDENT AUDIOLOGY

REASON/S FOR REFERRAL