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Audiologist may elect to not perform ABR evaluation if hearing loss is ruled out with behavioral/ OAE tests. Texas Children s Referral Form Phone 832-822-3249 Patient Information Last Name Middle Initial First Name Date of Birth Gender circle Male / Female Street Address City Parent s Name Cell Phone State Zip Code Alternate Phone Reason for Referral Failed hearing screening Genetic disorder/syndrome Speech delay Did not pass newborn screen Did not have newborn hearing screen Otitis media...
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