Hearing Test Parent/Guardian Consent Form

Please complete the following prior to your appointment


I consent to my child

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.  

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

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.