Victorian Infant Hearing Screening Program

Audiology referral

  • Form

    VIHSP audiology referral form

    When to use this form

    Download this form to refer infants and children (0-5 years) for a hearing test, including infants or children with a risk factor for late onset hearing loss.

    Once completed, this form can be either sent directly to the audiology centre or taken to the audiology centre by the parent. VIHSP does not require a copy of your completed form.

    View a list of Paediatric Audiology Centres in Victoria.