Get Cochlear Implant Referral Bformb Phone 604-875-b2345b Ext Bb

Filling out the Cochlear Implant Referral Form is a crucial step in obtaining assessment and support for individuals with hearing loss. This guide provides clear, step-by-step instructions to ensure the form is completed accurately and efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access and open the form in your chosen digital editor.
2. Fill out the referral source section with your name and contact telephone number. Ensure you include all contact details accurately.
3. In the address section, provide the complete address pertinent to the referral. This includes street, city, and postal code.
4. Enter the child's name, date of birth, and sex. This information is important for the identification of the individual referred.
5. Write down the BCCH unit number and Personal Health Number (PHN) if available.
6. Provide the names and telephone numbers of the parent or guardian, ensuring their contact information is current and correct.
7. Indicate the primary language spoken in the home, and whether an interpreter is required.
8. Confirm if the parent or guardian has been notified before the referral by selecting 'Yes' or 'No'.
9. Input the family physician's and audiologist's names and contact numbers.
10. List the early interventionist or hearing resource teacher's information, if applicable.
11. Detail the preschool or school attended by the child, if applicable.
12. Specify the primary mode of communication preferred.
13. Note the date of hearing loss diagnosis and the date hearing aids were fitted.
14. Describe the consistency of hearing aid use and the etiology of the hearing loss.
15. In the reason for referral section, check the relevant options provided.
16. Enclose all audiology results, including ABR waveforms and any available intervention reports.
17. Ensure that the physician referral to Dr. Kozak is completed, along with any best referral processes if applicable.
18. Decide how to submit the form; you can either fax it to the provided number or mail it to the specified address. Ensure you follow the correct procedure.
19. Once all fields are completed, you can save changes, download, print, or share the form as needed.

Complete your Cochlear Implant Referral Form online today to initiate the referral process.