Please select your title?—Please choose an option—MissMrMsMrsMasterDrMx

Full Name

Email Address

Name of GP Surgery

Which ear do you need Wax Removal?—Please choose an option—Left EarRight EarBoth Ears

Do you suffer from Tinnitus?—Please choose an option—YesNo

Do you suffer from Hyperacusis? (Hyperacusis is when everyday sounds seem much louder than they should)—Please choose an option—YesNo

Are you currently undergoing Radiotherapy?—Please choose an option—YesNo

Are you Diabetic?—Please choose an option—YesNo

Do you wear hearing aids?—Please choose an option—YesNo

Do you normally struggle with your hearing?—Please choose an option—YesNo

Do you suffer from any condition that causes balance problems or vertigo attacks?—Please choose an option—YesNo

Have you suffered from any pain in your ears within the last 30 days?—Please choose an option—YesNo

Do you have a perforated ear drum?—Please choose an option—YesNo

Have you tried to remove the ear wax yourself?—Please choose an option—YesNo

Are you currently under ENT consultant or receiving any treatment regarding your ears?—Please choose an option—YesNo

Are you currently using any anti-coagulants? E.g. Warfarin, blood thinners, Aspirin—Please choose an option—YesNo

Are you aware of any reason as to why you should not proceed with microsuction/water irrigation?—Please choose an option—YesNo

Have you had Ear Wax removed from your ears previously?—Please choose an option—YesNo

How did you come across our services?

Do we have your consent to send your GP a record of completion?—Please choose an option—YesNo

Ear Wax Removal via Microsuction is considered safer than other methods such as syringing. The Ear Wax Removal will be carried out by a trained clinician working to the protocols set out within the Ear Wax Removal Clinic's TM Aural Microsuction Procedures Manual. Complications of Ear Wax Removal that Microsuction are uncommon; however possible complications, side-effects and material risk inherent in the procedure include, but are not limited to: incomplete removal of ear Wax requiring a return visit (for severely impacted wax), minor bleeding, discomfort, ringing in the ear (Tinnitus), perforation of the ear drum and hearing loss. To ensure the risk of complication is minimised, it is essential that accurate past medical history is supplied to our clinicians. In addition, it is important the patient remains relatively still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding.

By agreeing to the Terms and Conditions above, you accept that you have read and understand the possible complications that may occur and agree that Hear4U's Hearing Specialists, or any of its employees, cannot be held responsible for these. I have read and understood these terms and conditions and am willing to be bound by them.

Microsuction is a system which effectively uses a vacuum to clear out any debris or wax from the ear canal. There is currently only one CE-marked equipment to use; however, it is common practice to use off-label devices: The CE marked suction unit is to remove fluids from the airway or respiratory support system and infectious materials from wounds and has been adapted for aural micro suction. In the procedure of microsuction, a fine suction tube is gently inserted into the ear canal while being viewed closely through a microscope or magnifying Loupe headsets.

Statement of Consent:

- I understand that personal information is held about me.

- I have had the opportunity to discuss the implications of sharing or not sharing information about me.

Please sign below: