Consent to Collect;

Use and Disclose Information and for Audiological Evaluation (Hearing Test)

The Audiologist will be generating a personal record from the information collected. This record will be securely maintained for 10 years following last contact and from the patient reaching the age of 18. PHS will be the custodian of your record.

You will have access to your record and may choose to allow PHS to share your information accordingly, we will get your explicit consent to do so. Exceptionally, members of your healthcare team e.g. Family Doctor are considered to be part of your “Circle of Care” and we will assume your consent, unless you advise otherwise.

The Audiologist will gather information about you/your child’s general health and history as it relates to hearing, as well as assessment data. This will assist the Audiologist in determining the nature of any hearing issues and possible management approaches. Various aspects of auditory function will be evaluated, including hearing sensitivity. Some tests will not require any response from you; others will call for you to indicate when you’ve heard a sound or to repeat words. Test results will be communicated to you, and where appropriate recommendations will be made to assist in your hearing function.

Benefits: Your hearing status and whether treatment is necessary to improve your hearing will be determined.

Risks: You may hear some loud sounds and/or feel some pressure changes that may cause momentary discomfort. In the unlikely event that you experience any pain, test administration can be immediately terminated.

Do we have consent to assess your child’s/your hearing, to collect and use your health information?


1371 Neilson Road, Suite 317A
Scarborough, Ontario, M1B 4Z8
Phone: (416) 286-9800


601 Harwood Ave. South, Unit 106
Ajax, ON, L1S 2J5
Phone: (905) 428-7555


220 Dundas Street West, Suite 405
Whitby, ON L1N 8M7
Phone: (905) 666-8000


222 King St E, Suite 1103A
Bowmanville, ON L1C 1P6
Phone: (905) 623-1994


300 King Ave. East
Newcastle, ON, L1B 1J8
Phone: (905) 987-5252