Preferred Physician Program

Preferred Physician Form

Thank you for the referral. Reports will be returned within 48 hours

Referring Provider(Required)

Referring Physician Name

Phone

Signature

Date

Patient Information(Required)

First Last

Phone

Email (optional)

Reason For Referral (Check All That Apply)

Hearing Evaluation

Tinnitus Evaluation & Management

Hearing Aid Evaluation/ Repair/ Trial

Ear Wax Removal

Other: ________________________________

Notes/ Special Requests

It is often the small things that hold us back from making a decision. That’s why we are on hand to help.

Simply complete the Callback form to request a friendly, no-obligation conversation with one of our helpful team members.