e-referral Please enable JavaScript in your browser to complete this form.EarPain or infectionHearing lossTinnitus or vertigoWaxOtherNoseSinusitisAllergic rhinitisNasal obstructionRhinorrhoeaSnoringEpistaxisLoss of smellOtherThroatTonsillitisPain or discomfort or globus sensationNeck massVccOtherSkull base / otherSkull baseOtherUrgent?YesPatient Name *FirstLastDate of birth *Patient phone number *Patient email addressComments (relevant medical history, medication lists, allergies etc.) *Investigations orderedCT scanMRI scanBlood testsBiopsy / histopathologySleep study / polysomnogramAllergy testsBarium swallowAudiogramOtherReferring doctor *Provider number *SignatureClear SignatureReferrer clinicHealthlink EDI, email address or fax number *Email address for copy of submitted referral form (optional)Submit