Client Information:

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Your Name(Required)
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Hearing Impaired
What Services are Requested?(Required)
Referral Source Name(Required)
Note to health care providers only: please fax any additional relevant information (e.g., hospital discharge summary) to (206) 420-0951. If you are referring a patient for a Low Vision Evaluation, please complete: https://lhblind.org/doctor-referral-for-clinic/