Please attach a copy of your examination sheet to this form if

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Please attach a copy of your examination sheet to this form if Powered By Docstoc
					                      Program for Amplification for Children of Texas (PACT)
                                Report of Otological Examination

       Name of PACT participant                    PACT file #               DOB                Date of
                                                                                              Examination




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
   aids.

___The person listed above has a medical condition that is noted on the attached
      examination form*:

        ___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

                                                                    ______________________
                                                                    Address

                                                                    ______________________
                                                                    City/State/Zip

                                                                    ______________________
                                                                    Telephone #


*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).