I have given consent to an audiologist from Melody Hear For You to test my hearing. I understand that a hearing test report will be provided after the appointment.

I understand that all records are confidential and governed by the Privacy Act.  I agree that the results of these tests be provided to the referring doctor as recorded in the consent form. Provision of results to any other person or agency will require my written consent.

Please complete payment at least 24hours before the appointment by credit card (sub-charge applies) or direct bank transfer as specified on your invoice. If due to unforeseen circumstances we need to cancel your appointment, a full refund will be provided. 

Please provide your Medicare number and referring doctor’s name if you would like to partially claim back your hearing test.