Appointment Location* Richmond Narre Warren Bellerive
Who is your doctor?
How did you hear about us?*
--- Internet/Google Yellow Pages Newspaper Doctor Walking/Driving Past Radio Facebook Friend/Relative Other
Date of Birth*
Select State* NSW VIC QLD SA WA TAS ACT NT
Do you consent to your report being sent to your doctor?*
How would you like to receive your report?*
Do you want to receive the newsletter three times a year?*
Yes, by email Yes, by post No
Is the patient on a pension card or health care card?*
Pension Card Health Care Card Neither
Is the patient on a DVA card?*
No White Gold
Patient Medicare Number
Hearing & Ear Health History (Adult)
How would you rate your hearing on a scale of 1 to 10?*
(1 = terrible, 10 = excellent)
Select 1 2 3 4 5 6 7 8 9 10
Have you ever had or are you suffering from:
All questions are required to be answered
Tinnitus (ringing in ears)
Blood Thinning Agents
If required, do you consent to wax removal using microsuction and/or curettage?
Attach Your Referral (If available)
Eastern Audiology is proud to provide audiology services in the following:
Audiology Australia and Independent Audiologists Australia’s Code of Conduct, Code of Ethics and Professional Practice Standards.
Hearing Services Program (HSP) best practice principles.
Eastern Audiology is an independent and privately-owned audiology clinic and does not have any obligations to or specific sales targets with any one manufacturer.
Eastern Audiology staff members do not receive any commission for devices fitted nor do they have any sales targets.
Eastern Audiology may access discounts from any or all manufacturers, including Phonak, Unitron, Widex, Starkey, ReSound, Oticon, Sonic Innovations, Bernafon & Signia, to provide competitive pricing to our patients.
Eastern Audiology Staff Conduct
At all times the staff at Eastern Audiology will work to their utmost to provide you with the very best in hearing health care. Should you have any concerns with their conduct at any times we encourage you to discuss this with management.
The staff at Eastern Audiology deserve to work in a safe, rewarding and respectful environment. Disrespectful and/or threatening behaviour will not be tolerated. Should this occur you will be asked to leave the clinic immediately. All subsequent communication will be with management only.
Payment of Services
Unless prior arrangements have been pre-approved with management all accounts are to be settled on the day of service, including hearing aid fitting.
Private Health Insurance
HICAPS is not available for audiological services or hearing aids. However, all information required for claims to be made with your private health insurer is available on your receipt. Entitlements are to be claimed directly with your insurer.
All accounts not paid for on the day of service will incur a $10 administration fee. If the account is not paid in full after the second reminder the account will be forwarded to a third-party debt collection agency.
Missed or Rescheduled Appointments
We request 24 hours’ notice to cancel or reschedule an appointment. This is to allow Eastern Audiology time to fill the time otherwise allocated for your appointment. If you fail to give notice, a missed appointment/late cancellation fee may be applied. If this occurs more than once all appointments will be required to be pre-paid. Should pre-paid appointments be missed a refund will not be provided.
I confirm that I have read and agree with the terms and conditions above from the date this form is submitted.