Patient Referral — Burlington Hearing Centre

Patient Referral

Complete the following online form with your patient information and a member of our team will call your patient to schedule an appointment.

Or print out the referral page and fax it to our clinic at 289-635-2350.

Burlington Hearing Centre - Patient Referral Form

Name of Referring Professional

Phone Number of Referring Professional

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Patient Name

First Name

Last Name

Patient Phone Number

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Reason for Referral