Hearing Test Parent/Guardian Consent Form

Please complete the following prior to your appointment

First Name*

Last Name

Contact Number

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I consent to my child

Child's Full Name*

Child's Date Of Birth*

being seen by an audiologist from Melody Hear For You for a hearing test. I understand that a hearing test report will be provided after the appointment.

My child passed their newborn hearing test.*

Yes

Unsure

My child currently has / in the past had grommets (ventilation tubes) in their ears.*

Yes

My child has a diagnosed disability or other developmental delay*

Yes

My child has seen a Ear, nose and Throat specialist before*

Yes

My child has a family history of hearing loss*

Yes

If Yes, please provide details

I have concerns about my child’s ability to talk, understand or hear others talk*

Yes

If Yes, please provide details

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

Medicare Number

Referring Doctor's Name

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 agent 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.

Parent/Guardian's Signature*

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Date*