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:
(E.g. Warfarin)
(or signature of a parent if under 16, guardian or attorney if appropriate)
This form is completed to the best of my knowledge.

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