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Cochlear Implant Referral

Referrals form

Referrals process


  1. Check that the patient meets the criteria as set out in the Cochlear Implant clinic page.
  2. You can refer a child if you are a parent, audiologist, teacher or physician.
  3. A physician referral to Dr. Kozak will eventually be needed but can be done after initial referral to the team.
  4. We accept referrals for children birth to 18 years of age.
  5. If you are not sure if a child will benefit from a cochlear implant it is best to refer.
  6. Download the referral form and fill it out.
  7. Fax OR mail the form. 
SOURCE: Cochlear Implant Referral ( )
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