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Request for Medical Clearance for
Extended Wear Hearing Aid(s)
Request for Medical Clearance for Extended Wear Hearing Aid(s)
Date:
Patient Name:
Date of Birth:
Your patient,
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.
Request for Medical Clearance Re:
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
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
________________________________________
Physician Signature
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
Please Fax Back To:
Clinic Name: _____________________________________
Fax: ____________________________________________
, is interested in being fit with Lyric hearing aids (please see reverse side for
o Other: ______________________________________
______________________________________
______________________________________
______________________________________
_______________________
Hearing Professional Name: ____________________________
____________________________________________________
Hearing Professional Signature
Date
13
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