Make a Referral

At Island Hearing we welcome physician, employer and health care professional referrals. You can make a confidential referral by emailing or faxing us the patient’s name and telephone number or completing the attached form. In most instances we will contact the client within 2 working days of receiving the referral. A report will be faxed, e-mailed, or mailed to you after the patient’s evaluation.

PLEASE SEE MY PATIENT

Patient Name:

Patient Phone Number:

Referred By:

Send Test Results To:
(Please include address and/or fax number.)

Date:

Fees apply to above services

APPOINTMENT
Comments:

Fax: (250) 383-6664