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Celtic Hearing Hearing Aid Shop Swansea Carmarthen Hearing Aid Shop Swansea Carmarthen

01267 222283 (Carmarthen) | 01792 465297 (Swansea)

info@celtichearing.com

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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*
MM slash DD slash YYYY
Please select your preferred local branch of Celtic Hearing*
Consent*
I have read and understood the terms of service and am willing to be bound by them.
Click here to read our privacy policy.

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MAIN OFFICE

Celtic Hearing Carmarthen, 17 Lammas Street, Carmarthenshire, SA31 3AQ

01267 222283

info@celtichearing.com

SWANSEA BRANCH

Celtic Hearing Swansea, 3 Mannheim Quay, Maritime Quarter, Swansea SA1 1TS

01792 465297

info@celtichearing.com

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Micro Suction Ear Wax Removal Consent Form

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