Consent

Please take the time to complete the form below. Upon completion, please hand the iPad back to our receptionist and inform them it has been completed.

If you have any questions regarding the form below, please do not hesitate to ask!

Full Name *

Email Address

First Line of Address *

Town *

Postcode *

Contact Number *

Date of Birth *

Name of GP Surgery *

Which ear do you need Wax Removal? *

Do you suffer from any condition that causes balance problems or vertigo attacks? *

Have you had a vertigo attack in the last 30 days?

Do you suffer from any pain in your ears within the last 30 days? *

Do you have a perforated ear drum? *

Which ear is perforated?

Have you tried to remove the ear wax yourself? *

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

Please state ENT details and/or treatments you are receiving regarding your ears

Are you currently using any anti-coagulants? E.g. Warfarin *

Are you aware of any reason as to why you should not proceed with microsuction/water irrigation? *

Please describe why you think you should not proceed

Have you had Ear Wax removed from your ears previously? *

How did you come across our services? *

Ear Wax Removal via Microsuction is considered safer than other methods such as syringing. The Ear Wax Removal will be carried out by a train 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.

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:

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