Suite 1204-1 Newland St Bondi Junction NSW Australia 2022 (02) 9387 3599 F (02) 9387 6130 adiminghealthyhearing.comau ‘wwcheathyhearing.comau Cd HealthyHearing &BalanceCare Patient's Name: Referral Date: Referrer:Dr Prov.No: Address: Tel Fax: Email: Reason for referral: Drs Signature O Hea 1g Assessment 1 Audiogram 2 Tympanogram C1 OAE C1 VROA 1 Balance (Vestibular) Assessment (seereversfor instructions) COYNG CCalorics CHallpike CVEMP CvHIT D Auditory Evoked Potentials DECochG CABR CiCorticals D. Auditory Processing CAPT CIABR CICAEP D1 Tinnitus DAssessment Di Treatment D Hearing Aids DiAssessment CFitting DService O Cochlear implant DAssessment DiFitting OMapping DService (C1 BAHA DAssessment Dfitting DService C Earplugs C Musician's CNoise D1 Swimmers CO ENTReview Patients undergoing VNG test for balance assessment please note the following instructions: 1.No alcohol intake for 48 hours before the test. 2.No smoking for 12 hours before the test. 3,Sleeping tablets, antihistamines, medication for dizziness (or nausea, should not be used for at least 4 days prior to the test (check with your doctor). 4. Medication for heart, blood pressure and epilepsy should be CONTINUED. 5.No face make-up. Newland st Estates Hart Coles 8 Parking Healthy Hearing and Balance Care is located at: Suite 1204, 1 Newland St, Bondi Junction, just 50 metres from the train station. For appointments please call 9387 3599. 2