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Medical Clearance Form
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Medical Clearance Form
domsears14
2018-04-22T11:29:21-04:00
Medical Clearance Form
Instructions
PLEASE PRINT THIS OUT AND HAVE YOUR DOCTOR FILL IT OUT-OR-YOU CAN ASK THEM TO FILL IT OUT ONLINE AND SUBMIT IT ON YOUR BEHALF.
Date
Patient Name
Date of Birth
I have evaluated the following patient named below for amplification:
Patient Name
And have found the following:
Checkbox
No limitations-patient may be fitted in either ear with an appropriate syle hearing aid(s)
Open venting hearing aid due to potential outer or middle ear pathologies in right______ left_______ Binaural_______ear(s)
Other
Any Additional Comments:
Doctors Name
Doctors Signature
Verification
Please enter the number 19 so we know you are human
*
This box is for spam protection -
please leave it blank
:
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