Get Download Referral Program - Nova Scotia Hearing And Speech ... - Nshsc Nshealth

Filling out the Download Referral Program form for Nova Scotia Hearing And Speech is essential for ensuring that individuals receive the appropriate evaluations and services. This guide provides clear, step-by-step instructions to help users complete the form efficiently and accurately.

Follow the steps to complete the referral form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the person's name, starting with their last name followed by their first name and middle initial.
3. Fill in the date of birth using the format DD/MM/YYYY.
4. Indicate the sex of the individual by checking the appropriate box for Male or Female.
5. Enter the health number of the individual and indicate the province, choosing 'NS' for Nova Scotia or entering a different province if applicable.
6. Provide the expiry date of the health card in the format DD/MM/YYYY.
7. List the next of kin’s name and their telephone number.
8. Complete the address section, including the street address, apartment number, city, province, and postal code.
9. If the individual has been seen previously by the Nova Scotia Hearing and Speech Centres, indicate this by checking ‘Yes’ or ‘No’.
10. Enter the home and work telephone numbers, if available.
11. Document where the individual was previously seen and their chart number, if applicable.
12. Fill in the family doctor's contact information.
13. Input the referral source’s name, company or agency name, address, postal code, and telephone number.
14. Specify any special procedures necessary for the case.
15. Select one or more services required by checking the appropriate boxes for evaluations.
16. If the services are needed for employment, insurance, or pension purposes, indicate ‘Yes’ or ‘No’ and provide a brief explanation if applicable.
17. Describe any symptoms or reasons for the referral in the designated section.
18. Indicate any medical contraindications for a hearing aid evaluation and whether a referral to a specialist in otolaryngology is necessary.
19. State if there are any accessibility or cultural considerations and provide details if needed.
20. Complete the optional section where you agree to allow a specified person to receive information regarding the appointment.
21. Once all sections are filled, save changes, and proceed to download, print, or share the completed form.

Complete and submit your referral form online for timely assistance.