Ear Wax Consent Removal 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: Do you suffer from any condition that causes balance problems or vertigo attacks?* Yes No Have you had any fluid discharge from your ear/s within the last 30 days?* Yes No Have you suffered any pain in your ears within the last 30 days?* Yes No Are you aware of, or suspect you may have a perforated ear drum?* Yes No Have you tried to remove the wax yourself other than using ear drops?* Yes No Have you had any surgical operations on your ears, nose or throat?* Yes No Are you currently under an ENT Consultant or receiving any treatment regarding your ears?* Yes No Are you using any antiplatelet or anticoagulant blood thinners? E.g. Warfarin.* Yes No Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?* Yes No Have you had wax removed from your ears previously?* Yes - Micro Suction Yes - Other No Are you aware of any reason as to why you should not proceed with micro suction?* Yes No Patient Name* First Last Patient Email* Patient Telephone Number.*Patient Signature*Does the signature belong to the patient?* Yes No Date of Signature* Date Format: MM slash DD slash YYYY Please select your preferred local branch of Celtic Hearing*SwanseaCarmarthenConsent* I have read and understood the terms of service and am willing to be bound by them.Click here to read our privacy policy.
