P AEDIATRIC A UDIOLOGY & A UDIOVESTIBULAR M EDICINE
R EFERRAL F ORM TO BE SENT TO
Barnet resident
or
Paediatric Audiology & Audiovestibular Medicine,
Children’s Services (Management)
Edgware Community Hospital
Edgware, HA8 0AD
Fax 020 – 8732 6474 (Tel: 6224)
email: paediatric.audiology@nhs.net
Paediatric Audiology & Audiovestibular Medicine,
Cedar House
St Michael’s Hospital
Gater Drive, Enfield EN2 0JB
Tel. 020 – 8375 2915
email: enfield.audiology@nhs.net
NHS No.:    -    -    
CHILD
First Name:
Enfield resident
Surname: ........................................................
.....................................................
.....................................................
(BLOCK CAPITALS)
.................................................................................. (BLOCK CAPITALS)
Gender:
M/F
DOB:
........................................ Ethnicity: .............................................
Address:
........................................................................................................................ (BLOCK CAPITALS)
............................................................. ................. Postcode:   ....
Guardian / Parent
Please circle: parent / legal guardian / foster carer / …………
First Name: .....................................................
Gender: M / F
(BLOCK CAPITALS)
Surname:
.....................................................
DOB: ................................................................
(BLOCK CAPITALS)
Email address: .......................................................................................................................................
Telephone:
....................................................................... Mobile: ............................................................
Nursery / School: ..................................................................................................................................
GP:
.....................................................
H.V/SNP: ........................................................
Urgency:
Routine / Urgent: (PLEASE STATE WHY)
........................................................
Referrer:
Name:
Address:
Signature:
.....................................................
(BLOCK CAPITALS)
Designation: ..........................................................
.....................................................
...............................................................................
.....................................................
Date: .....................................................................
S PEC IF IC R E QU EST S :
Consultant opinion 
Patient / Parent agreed to referral:
Interpreter required? :
Support to attend required?:
Medical advice 
Hearing assessment 
 Yes  No
 Yes which language? ..................................................................................................
 Yes, which type?
......................................................................
Turn over to complete the form
Paediatric Audiology & Audiovestibular Medicine referral form
Page 2 of 2
If part of an 18-week pathway specify time of start: …..…..…. Dx: ........................................................
Reason for referral:
(incl. degree of concern)
Medical and Developmental History:
1)
2)
3)
4)
5)
6)
Diagnosed Condition
Speech & Language Development:
Motor Development:
Social Communication Problems:
ENT & audiology consultations:
…
Family History:
(including sensory-neural hearing loss):
Newborn hearing screening result:
Passed / Missed Appointment / Failed to attend / Incomplete
Details:
School Entry Hearing -Screen /
Surveillance only (please indicate):
Passed / Missed Appointment / Failed to attend / Incomplete
Details:
Other Professionals Involved (incl. name & address –or CAF copy–
Paediatrician:
Sp & L Therapist:
ENT surgeon:
other:
and attach recent reports):
......................................................................................................
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For Office use only:
PaedAudRef 07-2014
Clinic allocation:
Cx / CA / 2A / A3 / A5 /
Time frame:
Routine
Date allocated:
..................................................................
/ Urgent
/ …………………