Audiometric Results Release Form

Please read and fill out the form below.

I hereby authorize TestTech Occupational Testing Solutions Inc. to release my audiometric testing results to my employer.

I understand the information that will be provided are confidential medical records and that TestTech Occupational Testing Solutions Inc. is not liable for the use(s) of such records by the above named company.

I Agree

I Disagree

The information that may be released will include the following:

Hearing History | Noise Exposure | Audiogram Results | Possible Hearing Loss/Hearing Shift | Referral to Audiologist

I agree that by signing this consent I am releasing my right to protections under the Occupational Health and Safety Code: Part 16 Section 223 (5)

I Agree

I Disagree

Donor Name

First Name

Last Name

Donor Signature

By typing your name here you are accepting all of the above

I accept the above typed name as my signature for the purpose of this release form.

Yes

Date

MM

DD

YYYY