An audiology referral form that says how to reach the patient

The referral is about hearing loss. The clinic's first move is to phone them.

There is a small absurdity at the heart of nearly every audiology referral, and almost no template in the search results deals with it. You are sending a patient because they cannot hear well. The hearing clinic's first action on receiving the referral is to ring them and get no answer, then ring again the next day and get no answer, and the referral quietly goes nowhere while everybody assumes somebody else is chasing it. An audiology referral form that works says how to reach this particular patient — a text message, an email, or a named family member who has agreed to take the call — before it says anything clinical at all. This preset starts there, then covers the reason for the evaluation, the testing that already exists, and who needs the report when it is done. It opens already populated, every field is editable in plain language, and a printable PDF is ready as soon as the page loads. No account, no email wall, nothing withheld to make you create one.

• Built for HIPAA-compliant workflows

• Free to start — 50 patient actions each month

What an audiology referral needs to carry

Patient name, date of birth and contact details, with the preferred contact method given real space rather than a phone line and nothing else, plus insurance or payer details where your workflow includes them. The referring practice and clinician with phone, fax and NPI where one applies, and the referral date. Then the clinical entry, written by the referring clinician: the reason for referral and what the patient or family reports, which ear or ears are involved, how long it has been going on, and whether anything has changed. Relevant history a hearing clinic wants in advance — ear surgery, perforations, discharge or pain, tinnitus, dizziness or balance problems, noise exposure at work or in service, family history, and any medication known to affect hearing, including ototoxic therapy the patient is on or about to start. The status of previous testing: whether an audiogram or tympanogram exists, roughly when, and where the clinic can obtain it. Then the requested service, who should receive the report, and the referring clinician's signature and date. Practices that distribute a hearing clinic referral to the offices around them usually pre-fill their own details first.

Who needs the result, and what decision it is feeding

The second field this preset takes seriously is the one that decides whether the appointment produces something useful: what the evaluation is for, and where the result has to go. Hearing test covers at least five very different appointments. A baseline before a course of ototoxic therapy is time-critical against the treatment start date. A pre-surgical evaluation goes back to a surgeon who needs it by a particular clinic date. A school-based evaluation may need to reach a named coordinator as well as the parents. An occupational hearing conservation re-test is compared against one specific earlier record. A hearing aid consultation is a different appointment again, with a different length and a different person in the room. So the form asks the referrer to name the reason and to name a second report recipient where one exists, rather than sending everything back to the referring office and leaving the patient to carry a copy across town. The audiologist decides what to test and how; the referral simply stops them guessing why they were asked.

Edit it, then download exactly what you built

Rename the form, rewrite any label or helper text, mark fields required or optional, and add, duplicate, reorder or remove sections. A pediatric practice referring for school and speech concerns wants a different document from a primary care office referring older adults for a hearing aid consultation, and an audiologist referral form that a hearing clinic hands to the practices around it usually arrives with its own address, fax line and report preferences already filled in. Expand the previous-testing rows if your patients tend to arrive with a history of them. Delete the sections you never complete. A default PDF is available the moment the page loads, and after any change a new PDF is generated from your current version, so what you print or fax is the version you built rather than the original preset — and reset restores it if an edit goes too far. It fits US Letter, prints legibly in black and white and survives a fax machine.

A primary care practice and the hearing clinic it refers to

A three-physician primary care practice sends most of its hearing patients to one clinic four blocks away, and between them they rebuild this preset in an afternoon. The contact block moves to the top and becomes required, with text, email and a named family contact who has agreed to be called, after a run of referrals that were never booked because nobody picked up the phone. A second report recipient line is added, because results had been going back to the referring physician while a surgeon or a school waited on a copy. A previous-testing line is added so the audiologist can compare rather than start from nothing. And the degree of hearing loss dropdown that had sat on the old pad for years comes off entirely: nobody at the referring end was in any position to fill it in, and the one place that answer legitimately comes from is the booth. One version, one printed pad, and the clinic starts reaching patients on the first attempt.

What the referring clinician owns, and what belongs in the booth

Every clinical field here is authored by the referring clinician and recorded exactly as written. The front desk can complete the patient details, the contact preferences and the payer block, but the reason for referral is the clinician's to write. Beyond that, the form is deliberately quiet. It offers no hearing-loss diagnosis and states no degree, type or configuration of loss. It interprets no test result of any kind — not an audiogram, not a tympanogram, not an otoacoustic emission or any other measurement. Where previous testing exists it records that it exists, roughly when, and where to obtain it, and never what it showed. It recommends no hearing aid, no device and no treatment. And it rates no urgency and decides who is seen first for nobody: the audiology practice applies its own booking criteria when it reads the referral, and where a referring clinician judges that something needs to be seen quickly, that is their clinical judgement and their phone call, handled the way the two offices already handle anything that cannot wait. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, with BAA availability planned at launch.

Two documents, two authors, one appointment

The referral is written by you, about a patient you are sending. The background history for the evaluation itself is written by the patient or their guardian, about themselves — ear history per side, previous devices, noise exposure, in a level of detail no referral pad should try to hold. That is a separate preset and it is worth taking too. Both are free and both download without an account. Where a patient is being sent for a medical ear problem rather than for hearing measurement, an otolaryngology practice is the destination, and there is a preset for that as well. Beyond the paperwork: DocRepute is a HIPAA-focused patient-experience platform for independent US practices, in early access ahead of launch, whose digital intake workflow lets documents like these arrive typed and structured instead of handwritten. The free tier gives 50 action credits a month, used only when a patient completes a regular intake submission or a standard survey; building, editing and publishing forms uses none, and the free tier has no AI. Paid plans add AI intake, conversational surveys, and sentiment and topic analysis.