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BROOMFIELD HOSPITAL – AUDIOLOGY DEPARTMENT
GP DIRECT REFERRAL – AGE RELATED HEARING LOSS
Patient name:
NHS/Hospital number:
Address:
Tel no:
DOB:
Date:
GP direct access to audiology for age related hearing loss provides routine hearing assessment and the fitting of hearing aids
only. The service does not provide access to ENT (except in emergencies) and does not remove ear wax.
Prior to referral please tick boxes to confirm the patient meets all the required access criteria:
Yes
No
REASSESSMENTS has the patient had their current NHS hearing aid
for more than 5 years? – (excludes private aids)
Patient requires hearing reassessed and not replacement or
repairs to current hearing aids.
NEW PATIENTS - Is the patient over 50 years old?
Contact Audiology
Patient Access for
advice on Repairs and
Bookings: 01245 513237
Are both ears free of wax?
Manage Ear Wax in
Primary Care or Refer
through CRS
Refer to ENT
Hearing loss is similar in both ears? (i.e. no asymmetry)
Refer to ENT
The hearing loss has been gradual (no sudden hearing loss within
24hr or rapid, noticeable deterioration over previous 90 days)
Any recent ear infection?
Manage in Primary
Care or Refer to
ENT
Any significant otalgia?
Any significant vertigo / dizziness in the last 90 days?
Does the patient’s hearing fluctuate?
Patient reports unilateral or intrusive tinnitus affecting quality of
life?
Can you see a perforation in the TM (Tympanic Membrane)
Refer to ENT
Please advise if the referred patients will require assistance with:
□ Sight loss/dual sensory loss
□ Requiring translation services including language, lip reading and sign language
□ Learning Disabilities – as special test facilities and techniques are needed
□ Other – Please state ……………………….
Signed:
Print name:
Referrals should be sent by e-mail only to:
GP stamp:
[email protected]
Referral advice and information can be requested from the audiology department on 01245 513237
Updated January 2017