FORMS AND DOCUMENTS
CLINIC AND REFERRAL FORMS
Referral Form - Physician Referral
Referral Form - Educational Audiology
Appointment No Show Policy - Cerumen Management
Appointment No Show Policy - General
AHS and Covenant Health Medical Database Form
Grey Nuns Hospital Pre-Operative Database Form
Consent, Privacy and Release Form
Email Communication Waiver and Consent
CT & MRI Medical Questionnaire
MEDICAL FORMS AND QUESTIONNAIRES
Tinnitis Handicap Inventory (THI)
Tinnitus Questionnaire
Eustachian Tube Dysfunction Questionnaire
Client Orientated Scale of Improvement Questionnaire (COSI)
Abbreviated Profile of Hearing Aid Benefit Questionnaire (APHAB)
Hearing Handicap Inventory for the Elderly Questionnaire (HHIE)
Speech Spatial Qualities Questionnaire (SSQ)
Cochlear Implant Quality of Life Expectations Questionnaire (CIQOL)
HEARING AID FORMS
AADL - Application for Cost-Share Exemption for Hearing Aid Benefits for Seniors and Their Adult Dependants
AADL - Application for Cost-Share Exemption
AADL - Application for Temporary Cost-Share Exemption
AADL - Client Declaration
AADL - Validation Certificate
WCB Hearing Loss and Tinnitus Application
WCB Travel Reimbursement
VAC Hearing Loss and Tinnitus Medical Questionnaire
RCMP Hearing Loss and Tinnitus Medical Questionnaire
The Ear Clinic is a Registered Provider for the Following Funding Programs
VIDEOS
FORMS
Caring for your BAHA Implant
Covenant Health and Surgical Form
Form Three Title
Form One Title
Form Two Title
Form Three Title
Questions?
Please contact us for general inquiries, upcoming
appointments and surgical questions.
