Patient Details

Details of the patient that will attend the appointment

Name *

First

Last

Date Of Birth

Phone Number

Email Address *

1. Balance and Vertigo:

Have you experienced any balance problems, vertigo attacks, or had a vertigo attack in the last 30 days? *

Yes No

2. Ear Health:

Do you experience Tinnitus (e.g., ringing or buzzing in your ears or head)?

Yes No

Have you experienced any pain in your ears in the last 30 days?

Yes No

Have you had a perforated eardrum or any operations on your ears?

Yes No

Have you noticed any discharge from your ears?

Yes No

3. Wax Removal History:

Have you tried to remove earwax yourself?

Yes No

Have you had wax removal performed by a professional previously?

Yes No

4. Medical Consultation, Treatment, and Conditions:

Are you currently under the care of an ENT (Ear, Nose, & Throat) consultant or receiving any related treatments?

Yes No

Are you using anticoagulants (blood-thinning medication)?

Yes No

Are there any health issues that could affect your ability to give informed consent for procedures (e.g., dementia)?

Yes No

Ear Wax Removal Consent

Please Read Carefully

Procedure Overview:

Initial Check: We'll assess your ear health through questions and an otoscopy. Removal Methods: Depending on your condition, we may use:

Microsuction: Suction technique under magnification for precise debris removal.
Water Irrigation: Water pulses to flush out wax, suitable for healthy ear canals.
Manual Removal: Using instruments like the Jobson Horne probe to remove surface wax.

Clinician Expertise:

Procedures are performed by trained Audiologists or Hearing Aid Dispensers, adhering to high safety standards.

Potential Risks:

Minor risks include skin irritation, infection, temporary hearing changes, tinnitus aggravation, dizziness, or discomfort.

Additional Steps:

Olive oil or sodium bicarbonate may be applied if necessary. If wax isn’t fully removed, a follow-up might be scheduled.

In Case of Complications:

Referral to a medical professional if:

An infection is detected.
Damage to the ear is observed.
Discomfort persists post-procedure.
A foreign object is found.

Consent Rights:

You can withdraw your consent at any time and are encouraged to report any discomfort or concerns immediately.

Consent Agreement:

By proceeding, you consent to the removal techniques suited to your condition and acknowledge the risks involved. You agree that the procedure can be halted at your request.

I have read and agree to the above consent form

Patient Details

1. Balance and Vertigo:

2. Ear Health:

3. Wax Removal History:

4. Medical Consultation, Treatment, and Conditions:

Ear Wax Removal Consent

Procedure Overview:

Clinician Expertise:

Potential Risks:

Additional Steps:

In Case of Complications:

Consent Rights:

Consent Agreement:

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