Physician Referral Form

Referral form for physicians to refer patients to HearBright.

This form is for physicians and healthcare providers who wish to refer patients to HearBright for audiological services and hearing aid evaluation.

Instructions

  1. Healthcare providers should download this form
  2. Complete all required patient and referral information
  3. Fax or email the completed form to HearBright
  4. Patient will be contacted to schedule an appointment
Download Physician Referral Form (PDF)

For Physicians

When referring a patient, please include:

  • Patient demographics and contact information
  • Reason for referral
  • Relevant medical history
  • Any specific concerns or symptoms
  • Insurance information if available

For Patients

If your doctor is referring you to HearBright:

  • Ask your physician to complete this referral form
  • Contact us once the referral is submitted
  • We will schedule your appointment
  • Bring your insurance card and ID to your appointment

Questions?

Call us at 408-358-5123 for physician referral questions or to schedule a referred patient.