Pediatric Audiology Hearing Screening Referral

Pediatric Audiology Hearing Screening Referral — Form Fields

This healthcare template includes 11 fields. Referral form for children needing audiological hearing screening and evaluation. Free to customize and use on ZenBuild.

• Child's Name (text, required)
• Date of Birth (text, required)
• Parent/Guardian Name (text, required)
• Parent Email (email, required)
• Phone Number (text, required)
• Referring Provider (text, optional)
• Reason for Referral (dropdown selection, required) — options: Failed Newborn Screening, Speech Delay, Teacher Concern, Frequent Ear Infections, Parent Concern, Noise Exposure
• Child's Age (dropdown selection, required) — options: 0-6 Months, 6-12 Months, 1-2 Years, 2-4 Years, 5-8 Years, 9-12 Years, 13-17 Years
• Previous Hearing Test (multiple choice, required) — options: Yes, No
• History of Ear Tubes (multiple choice, optional) — options: Yes, No
• Describe Concerns (long text, required)