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TREATMENTS
CONSENT FORM
GP SERVICES
OLIVE OIL
CONTACT US
BOOK AN APPOINTMENT
CONSENT FORM
CONSENT FORM
Micro Suction Ear Wax Removal Consent Form
To safely remove any wax or foreign bodies present within the ear canal, it is important that the clinician is made fully aware of anything which may have a bearing on the procedure. Please answer the following questions regarding your hearing health by ticking and completing the relevant boxes:
Do you suffer from any condition that causes balance problems or vertigo attacks?
*
Yes
No
If you begin to feel even the the slightest bit dizzy or faint during the procedure it is important that you let the clinician know at the very first sign.
Have you had any fluid discharge from your ear/s within the last 30 days?
*
Yes
No
Have you suffered any pain in your ears within the last 30 days?
*
Yes
No
Pain Level
Slight
Significant
Excrutiating
Are you aware of, or suspect you may have a perforated ear drum?
*
Yes
No
Which ear?
Left
Right
Both
Have you tried to remove the wax yourself other than using ear drops?
*
Yes
No
Have you had any surgical operations on your ears, nose or throat?
*
Yes
No
Which one?
Left ear
Right ear
Nose
Throat
How long ago?
(Years, months)
Are you currently under an ENT Consultant or receiving any treatment regarding your ears?
*
Yes
No
Treatment Details
Are you using any antiplatelet or anticoagulant blood thinners?
*
Yes
No
(E.g. Warfarin)
Blood Thinner Details
Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?
*
Yes
No
Which ear/s?
Left
Right
Have you had wax removed from your ears previously?
*
Yes - micro suction
Yes - other
No
Are you aware of any reason as to why you should not proceed with micro suction?
*
Yes
No
Please discuss this with your clinician before signing this form.
Patient Name:
*
Last Name
*
Phone Number
*
Patient signature:
*
Clear Signature
(or signature of a parent if under 16, guardian or attorney if appropriate)
Does the signature above belong to the patient?
Yes
No
Signee Name
Reason for signee not being the patient
Date of signature:
*
This form is completed to the best of my knowledge.
Consent Terms
*
I have read and understood the
terms of service
and am willing to be bound by them.
Comment
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