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Request for Medical Clearance for Extended Wear Hearing Aid(s)
Date:
Patient Name:
Date of Birth:
Your patient, , is interested in being fit with Lyric hearing aids (please see reverse side for
description). Because these hearing aids are deep fitting and are worn for 2-4 months at a time, they present unique fitting
requirements. Outlined below are common contraindications and the specific concern for which we are requesting medical
clearance to proceed with Lyric as indicated.
Please Fax Back To:
Clinic Name: ___
__________________________________
Fax:
____________________________________________
Hearing Professional Name:
____________________________
____________________________________________________
Hearing Professional Signature
Request for Medical Clearance Re:
Physician Recommendation:
o
Patient can wear Lyric hearing aids
m
Left ear only
m
Right ear only
m
Both ears
o
Patient can not wear Lyric hearing aids and should be assessed for an alternative type of hearing aids
________________________________________ _______________________
Request for Cerumen Removal
Lyric fittings require that ALL cerumen is completely removed from the ear canal. There can be no cerumen visible and the
canal must be clean and dry prior to inserting Lyric. This patient is being referred for cerumen removal for the purpose of
fitting Lyric hearing aids.
Please remove cerumen from:
m
Left ear only
m
Right ear only
m
Both ears
Physician Signature
Date
o
Diabetes
o
Bruises easily and/or takes high dosage of anticoagulants
o
Allergy to chrome or nickel
o
Compromised immune function
o
Chemotherapy less than 6 months ago
o
Other: ______________________________________
______________________________________
______________________________________
______________________________________
Request for Medical Clearance for
Extended Wear Hearing Aid(s)