Comfort. Care. Hope.

Request an Audiology Appointment

Please complete the entire form below to request an Audiology appointment at Hotel Dieu Shaver.

Your Name: *

Patient's Name (if different than above): *

Patient's Health Card Number *

Patient's Current Address *

Patient's Date of Birth (YYYY/MM/DD) *

Reason for this appointment request *

I prefer to be contacted with details regarding this appointment by: *

Phone Call

Text Message

E-mail

Mail

Please complete the below field that corresponds with the preferred contact method you selected above:

Phone Number (Home)

Phone Number (Cell)

E-mail

Mailing Address (If you are the patient, type "same as above")

Notes or Comments:

Please Note: *

I acknowledge that there may be a fee for this service

Please Note: *

I acknowledge that there is a fee for hearing tests

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Renewing Hope. Rebuilding Lives.

Hotel Dieu Shaver Health and Rehabilitation Centre is a specialty hospital that excels in providing rehabilitation and complex care to thousands of patients across the Niagara Region.

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