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Hear4U
Earwax Removal Consent Form

Earwax Removal Consent Form

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!

 


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.

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.


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