Ear Wax Removal Consent Form

Name *

First Last

Email

Optional - but you'll receive a copy of the form

GP Surgery Name

PRACTICE NAME (not Doctor)

Date *

Have you had ear wax removed before? *

Yes - irrigation / syringing Yes - microsuction Yes - both the above No

How did you hear about us? *

Repeat customer Internet search Local GP Recommended - by friend etc

Please tick ALL applicable options below

1a. Contraindications to undertaking micro-suction *

Any previous problems with micro-suction? Ongoing history of severe dizziness? Unable to keep head still (i.e. Parkinsons)? None of the above

Details:

1b. Special precautions to undertaking micro-suction *

Ear pain - current or within 90 days? Troublesome tinnitus affected by loud noise? Anticoagulant medication? (blood thinners) None of the above

Details:

2a. Contraindications to undertaking irrigation (water spray) *

Previous problems having irrigation (or syringing)? Ear pain - current or within 90 days A confirmed ear infection within the last 90 days? (outer or middle ear) Mucoid ear discharge within the last year? Perforated ear drum that has NOT HEALED? - tick if unsure and add a comment Any operations on your ears - ever, including grommets? Cleft palate (repaired or not) None of the above

Details - i.e. approximate date, which ear, treatment:

2b. Special precautions to undertaking irrigation (water spray) *

Perforated ear drum confirmed has being healed? Prominent tinnitus? Recent dizziness? Impaired immune system - diabetes, cancer, HIV, HEP B, MRSA, etc Radiotherapy on the head / neck? None of the above

Additional information - i.e. approximate date, which ear, condition:

3. Additional questions *

Experienced recent metallic taste sensations ? Experienced recent facial tingling? None of the above

Which side? *

Note: this form is easier to sign using a touchscreen device - if you cannot sign it just press submit

Signature

Clear

I am signing on behalf of the patient (i.e. a person under 18 years of age, or an elderly person unable to sign) and agree to the terms of service on their behalf. *

No Yes

Parent / Guardian

First Name Last Name Relationship

Age of child

NOTE - We are not insured to do ear wax removal on children under 12 years of age. Please be honest about their age.

OUR TERMS OF SERVICE:

COVID Revision - By signing and attending you confirm that upon attendance you have not (within the preceding 14 days):

Developed a new or continuous cough
Developed a high temperature
Developed a general feeling of being unwell - not related to your ears
Developed a sudden loss of sense of taste or smell
Had corona-virus or been in contact with anyone who has
You are not supposed to be shielding

PLEASE CANCEL YOUR APPOINTMENT IF ANY OF THE ABOVE OCCURS

Your ear wax removal will be carried out by a trained clinician working to industry standard protocols. Wax removal may be done via micro-suction, irrigation /syringing, and / or dry tool extraction – whichever the clinician deems most appropriate based on the wax you present and your answers to this form.

Incidents during ear wax removal are very uncommon, however:

Minor complications that can occur which are deemed acceptable include: minor nicks or scratches to the ear canal which can also lead to minor bleeding, soreness, mild discomfort and short-term ringing in the ear (tinnitus). To minimise such risk please immediately notify the clinician of any discomfort or sensitivity to increased sound level.

Ear wax removal can cause slight dizziness in certain circumstrances - the client should inform the clinician if they feel dizzy and the procedure should be paused until the client feels stable.

More serious risk of damage to the ear canal or ear drum can occur if the client does not remain adequately still. Clients should inform the clinician of any discomfort or likely sudden movements, for example if likely to sneeze or cough. All equipment is sterilised or is single use only to keep infection risk to a minimum; however, there is always a risk that infection can set in once the client leaves the premises. Please contact the clinician for a free follow-up visit should you experience any discomfort of worrying pain, discomfort, swelling or discharge etc.

The CE marked micro-suction unit is designed to remove fluids from the airway or respiratory system and infectious materials from wounds. It has been adapted for aural micro suction and following risk assessment this has been approved by Barry Fenton professional indemnity insurance brokers. Representatives of Crystal Hearing are insured for professional indemnity with Barry Fenton Insurance Brokers - our certificates can be presented at any time.

Children must be 12 years of age or over.

PRIVACY STATEMENT - Your personal details will not be used for marketing whatsoever. By clicking to these terms you do agree that we may email you this form, we request a review off you, and that we may email you to inform you when the office is likely to be closed for staff holidays so that you can book future appointments.