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

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

Are you aware of, or suspect you may have a perforated ear drum? *

Yes
No

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

Are you currently under an ENT Consultant or receiving any treatment regarding your ears? *

Yes
No

Are you using any antiplatelet or anticoagulant blood thinners? *

Yes
No

(E.g. Warfarin)

Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)? *

Yes
No

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

Patient Name: *

Last Name *

Phone Number *

Patient signature: *

(or signature of a parent if under 16, guardian or attorney if appropriate)

Does the signature above belong to the patient?

Yes
No

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.

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CONSENT FORM

CONSENT FORM

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