Program for Amplification for Children of Texas (PACT)
Report of Otological Examination
Name of PACT participant PACT file # DOB Date of
Parent/Guardian’s Name: ___________________________________________________
Please check the statement that is correct for this person:
___The person listed above has been examined and can wear earmolds and hearing
___The person listed above has a medical condition that is noted on the attached
___The condition prevents the current use of a hearing aid.
___The condition is transient in nature and a hearing aid can be worn following
medical treatment of the condition.
Signature of Otologist
(Please Print) Physician’s name
*Please attach a copy of your examination sheet to this form if there is a
medical condition that prohibits use of a hearing aid.
8-10-2004 M-76 (Rev 8/2004)
Original with signature of the otologist should be sent to PACT with the request for hearing aid(s).