Referral Vestibular

Please submit details here:

Patient Name: Date of birth:

Street Address

Suburb Postcode

Contact Phone Number: Email Address:

Medicare Number Position Expiry Date

Pensioner Concession Card Number Expiry Date

Additional information:

Referrer details:

Organisation Referrer’s Name

Provider's Address

Suburb Postcode

Contact phone number Provider's Email

Provider number

Reason for referral

Assessments required: Standard vestibular assessment (Audiometry, VNG, cVEMP, oVEMP, vHIT)

Additional vestibular testing(e.g., calorics, Tullio/Fistula tests, VEMP thresholds, Electrocochleography):

Has a Cranial MRI been performed in the past six months to investigate this problem? (required) YesNo

Would you like ABR testing to investigate possible retrocochlear pathology? YesNo

Does your patient experience vertigo episodes greater that 20 minutes, aural fullness, tinnitus and have a documented low frequency hearing loss? YesNo

Post Assessment Management Options: Private vestibular physiotherapyPublic Vestibular Physiotherapy

Contact Us

Melbourne Hearing Care Clinic

Ground Floor, 550 Swanston St,
Carlton 3053
Phone: 03 9035 5333
Fax: 03 9347 1535
Email: aud-reception@unimelb.edu.au

Opening hours

Monday, Tuesday, Thursday & Friday
8:30 am to 4.30 pm

Wednesday
8:30 am to 7.30 pm
Closed public holidays

Directions

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