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

Medical Clearance Form

Verification