Hearing Test Referral by HC120914055633

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									                                      TOPEKA PUBLIC SCHOOLS
                                        NURSING SERVICES
                                      HEARING TEST REFERRAL

Dear Parent/Guardian:
Your child’s hearing is extremely important to his/her progress at school. During a school
screening program                                 ‘s hearing was tested. The results of hearing
                       (Student’s Name)
screening indicate a follow-up evaluation is advised. We believe an appointment with an
audiologist should be scheduled as soon as possible.

Further evaluation of your child’s hearing may be scheduled at the Quinton Heights Service
Center, 2331 SW Topeka Blvd. Please schedule an appointment with the Topeka Public Schools
Audiologist by calling 785-235-7572. This additional evaluation is without charge for students
enrolled in Topeka Public Schools, USD # 501.

It is important this form be returned promptly so that we can all best serve the needs of your
child.

Thank you for your cooperation.
Nursing Services Staff
---------------------------------------------------------------------------------------------------------------------

Parent/Guardian: Please complete and return as soon as an appointment has been made.

To: Nursing Services Staff

Student’s Name

An appointment has been made on                                         at                          for additional
                                            (Date)                 (Time)
audiology evaluation at the Quinton Heights Service Center, 2331 SW Topeka Blvd.

My child is under the care of Dr.

and was last seen on                                           , or has an appointment for

Parent/Guardian                                                                           Phone

Address

Distribution: White Copy – Parents/Guardians; Yellow – School File

Hearing Test Referral – English
Stockroom No: 861000
Revised: 4/08; 10/11
Hearing Test Referral – English
Stockroom No: 861000
Revised: 4/08; 10/11

								
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