This form contains 66 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Abbotsford Clinic Selection
Abbotsford	Checkbox	Check this box if Abbotsford is the selected audiology clinic for the referral.
Autism Assessment Referral Information
Family Doctor or Nurse Practitioner	Checkbox	Check this box if the referral is being made by a family doctor or nurse practitioner.
Pediatrician	Checkbox	Check this box if the referral is being made by a pediatrician.
Public Health Nurse	Checkbox	Check this box if the referral is being made by a public health nurse.
Autism or Developmental Delay Concern
Audiologist or Speech-Language Pathologist	Checkbox	Check this box if the referral is being made by an audiologist or speech-language pathologist.
ENT	Checkbox	Check this box if the referral is being made by an ENT.
Burnaby Clinic Selection
Burnaby	Checkbox	Check this box if you are selecting the Burnaby clinic for audiology services.
Child's Address
Child's Street Address	Text	Please provide the complete street address of the child.
Child's Postal Code	Text	Please provide the postal code for the child's address.
Child's Background Information
Child's School Name	Text	Provide the full name of the child's school.
Doctor/Nurse Practitioner Name	Text	Enter the full name of the child's doctor or nurse practitioner.
Other Language Spoken at Home	Text	If the child speaks a language other than English at home, specify that language here. Fill only if 'Language spoken at home – Other (specify)' is 'Yes'. Depends on: Language spoken at home – Other (specify)
Child's Personal Information
Child’s full name	Text	Enter the child’s legal surname followed by their first name in the format “surname, first name.”
Child’s preferred name	Text	Enter the name the child prefers to be addressed by, if different from their legal name.
Child’s date of birth	Date	Enter the child’s date of birth in day/month/year format (dd/mm/yyyy).
Child’s age	Number	Enter the child’s current age in years.
Other gender specification	Text	Enter the child’s gender identity if not male or female. Fill only if the 'Other' checkbox is 'Yes'. Fill only if 'Gender: Other' is 'Yes'. Depends on: Gender: Other
Chilliwack Clinic Selection
Chilliwack	Checkbox	Check this box to select the Chilliwack clinic for audiology services.
Family Indigenous Identity Status
Other risk factor for hearing loss, specify	Checkbox	Check this box when requesting a regular audiology assessment for another risk factor for hearing loss and specify the factor.
Pre or post-surgery audiogram	Checkbox	Check this box when requesting a regular audiology assessment before or after ear surgery.
Gender
Referred for autism assessment: Private	Checkbox	Check this box if the child has been referred for an autism assessment through a private provider. Fill only if the 'Concerns for autism or developmental delay?' is 'Yes'. Fill only if 'Concerns for autism or developmental delay – Yes' is 'Yes'. Depends on: Concerns for autism or developmental delay – Yes
Other, specify	Checkbox	Check this box when requesting a regular audiology assessment for any other reason and specify the reason.
Cytomegalovirus (CMV)	Checkbox	Check if the child has been diagnosed with cytomegalovirus (CMV).
Interpreter Requirement
Ear or head trauma, specify	Checkbox	Check if the child has experienced ear or head trauma; provide details in the specify field.
Sudden hearing loss (not related to middle ear fluid or infection)	Checkbox	Check if the child has experienced sudden hearing loss not related to middle ear fluid or infection.
Langley / Cloverdale / White Rock Clinic Selection
Langley, Cloverdale, and White Rock	Checkbox	Check this box if you are selecting the Langley, Cloverdale, and White Rock clinic for audiology services.
Language Spoken at Home
Meningitis	Checkbox	Check if the child has had meningitis.
Lab proven infection with high risk of hearing loss	Checkbox	Check if the child has a laboratory-proven infection associated with a high risk of hearing loss.
Maple Ridge and Mission Clinic Selection
Maple Ridge and Mission	Checkbox	Check this box if you are selecting the Maple Ridge and Mission clinic.
New Westminster / Port Moody / Coquitlam / Port Coquitlam Clinic Selection
New Westminster, Port Moody, Coquitlam and Port Coquitlam	Checkbox	Check this box if you want to select the New Westminster, Port Moody, Coquitlam and Port Coquitlam clinic.
North Delta Clinic Selection
North Delta	Checkbox	Check this box if you want to select the North Delta clinic for the audiology referral.
Parent/Guardian Information
Parent/Guardian 1 Name	Text	Enter the full name of the first parent or guardian.
Parent/Guardian 2 Name	Text	Enter the full name of the second parent or guardian, if applicable.
Primary Phone	Text	Enter the primary phone number for the parent or guardian.
Email Address	Text	Enter the email address for the parent or guardian.
Secondary Phone	Text	Enter the secondary phone number for the parent or guardian.
Reasons for Ruling Out Hearing Loss
Concerns for autism or developmental delay – Yes	Checkbox	Check this box if there are concerns for autism or developmental delay.
Concerns for autism or developmental delay – No	Checkbox	Check this box if there are no concerns for autism or developmental delay.
Gender: Male	Checkbox	Check this box if the child's gender is male.
Gender: Female	Checkbox	Check this box if the child's gender is female.
Referral Details
Personal Health Number	Number	Please provide the patient's personal health number.
Referral Date	Date	Please provide the date of referral.
Referral Source Role
Other	Checkbox	Check this box if the referrer's role is not listed among the other options and specify it in the accompanying field.
Referrer Information
Referrer Phone Number	Text	Enter the phone number of the person or entity making this referral.
Referrer Fax Number	Text	Enter the fax number of the person or entity making this referral.
Referrer Name	Text	Enter the full name of the person or entity making this referral.
Other Referrer Type	Text	Specify the type of referrer if none of the provided options apply. Fill only if 'Other' is 'Yes'. Depends on: Other
Referrer Type
Middle ear	Checkbox	Check this box if the audiology assessment is requested due to a middle ear issue affecting the child.
Suspected or known hearing loss	Checkbox	Check this box if the child is either suspected of having hearing loss or has already been diagnosed with hearing loss.
Other, specify:	Checkbox	Check this box if there is another reason to rule out hearing loss that is not listed, and provide details in the adjacent text field.
Speech delay	Checkbox	Check this box if the referral for audiology assessment is made because the child exhibits a speech delay.
School concern	Checkbox	Check this box if the child is being referred for audiology assessment due to concerns identified by their school or educators regarding potential hearing loss.
Parental concern	Checkbox	Check this box if the referral for audiology assessment is prompted by concerns from the child's parents or guardians regarding potential hearing loss.
Regular Audiology Assessment Request Reasons
Interpreter Required – Yes	Checkbox	Check this box if the family requires an interpreter.
Interpreter Required – No	Checkbox	Check this box if the family does not require an interpreter.
Does family identify as First Nations, Metis or Inuit? Yes	Checkbox	Check this box if the patient's family identifies as First Nations, Metis or Inuit.
Does family identify as First Nations, Metis or Inuit? No	Checkbox	Check this box if the patient's family does not identify as First Nations, Metis or Inuit.
Short Notice Appointment Availability
Referred for autism assessment: No	Checkbox	Check this box if the child has not been referred for an autism assessment. Fill only if the 'Concerns for autism or developmental delay?' is 'Yes'. Fill only if 'Concerns for autism or developmental delay – Yes' is 'Yes'. Depends on: Concerns for autism or developmental delay – Yes
Referred for autism assessment: Sunny Hill	Checkbox	Check this box if the child has been referred for an autism assessment at Sunny Hill. Fill only if the 'Concerns for autism or developmental delay?' is 'Yes'. Fill only if 'Concerns for autism or developmental delay – Yes' is 'Yes'. Depends on: Concerns for autism or developmental delay – Yes
Surrey - Guildford Clinic Selection
Surrey - Guildford	Checkbox	Check this box if you are selecting the Surrey - Guildford clinic for audiology services.
Urgent Audiology Assessment Request Reasons
Gender: Other	Checkbox	Check this box if the child's gender is other.
Can attend short notice appointment – Yes	Checkbox	Check this box if the patient can attend a short notice appointment.
Can attend short notice appointment – No	Checkbox	Check this box if the patient cannot attend a short notice appointment.
Language spoken at home – English	Checkbox	Check this box if the primary language spoken in the child’s home is English.
Language spoken at home – Other (specify)	Checkbox	Check this box if the primary language spoken in the child’s home is not English, and specify the language.
Urgent Request Specification
Urgent Request Other Specification	Text	Please provide details for any other urgent request for audiology assessment not listed above. Fill only if 'Other, specify' is 'Yes'. Depends on: Other, specify

REQUEST FOR SERVICES - PROVIDER, Community Pediatric Audiology Program Instructions