Ear Wax Removal Consent Form

PLEASE ONLY COMPLETE THIS CONSENT FORM ONCE YOU HAVE AN APPOINTMENT RESERVED.

To ensure wax removal is appropriate and can be performed safely, it is important that the clinician is made aware of anything which may have a bearing on the procedure. Please complete as accurately as possible.

Name*

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Address*

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Post Code*

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Telephone No.*

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E-mail*

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The e-mail address is invalid

Date of Birth*

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Do you suffer from any condition that causes balance problems or vertigo attacks? ( Yes or No )*

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If Yes, have you had a vertigo attack within the last 30 days? ( Yes or No )

Have you had any significant ear pain or infection within the last 90 days? ( Yes or No )*

This field is mandatory

Are you aware if you have a perforated ear drum? ( Yes or No )*

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If Yes, which ear and how long ago did this occur?

Have you had any surgical operations on your ears? ( Yes or No )*

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If Yes, what operation have you had and how long ago?

Have you had any cleft palate repair treatment? ( Yes or No )*

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Are you on any blood thinning (anticoagulants) medication e.g. Warfarin? ( Yes or No )*

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If Yes, does your blood clot easily if you have a small cut / abrasion? ( Yes or No or N/A )

Are you currently under an ENT consultant for any treatment regarding your ears? ( Yes or No )*

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Are you diabetic? ( Yes or No )*

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Are you having any radiotherapy or any other cancer treatment? ( Yes or No )*

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Do you have Hepatitis / HIV? ( Yes or No )*

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Do you have MRSA infection? ( Yes or No )*

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Do you have any tinnitus (ringing in the ears)? ( Yes or No )*

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If Yes, which ear and is it sound sensitive? ( Left / Right / Both )

Have you tried to remove the wax yourself? ( Yes or No )*

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If Yes, how did you try and remove the wax?

Have you had ear wax removal before? ( Yes or No )*

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If Yes, which method was used and when was this done?

If required, I agree to my GP being advised for an onward referral or treatment? ( Yes or No )*

This field is mandatory

GP name and address?

Microsuction is considered safer than other methods such as syringing. The procedure will be performed by a qualified clinician following guidelines written by The Hearing Lab & British Society of Audiology. Complications of ear wax removal are uncommon; however possible complications, side effects and material risks 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, infection, discomfort, tinnitus, perforation of the ear drum and hearing loss. To ensure the risk of complication is minimal, it is essential that accurate past medical history is supplied to the clinician. In addition, it is important that the patient remains very still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding. The CE marked suction unit is to remove fluids from the airways or respiratory support system and infectious materials from wounds and has been adapted for aural microsuction. It may be necessary to use other methods in addition to microsuction to ensure the safe removal of wax. This includes dry tools ( such as Jobson Horne, Rosen Inserter and Micro Forceps), Olive Oil and the Bionix OtoClear Ear Wash Spray Kit. The Bionix OtoClear Ear Wash Spray Kit uses body temperature water, at low pressure and at 30 degree angles to gently flush the ear canal avoiding direct pressure towards the ear drum. The clinician has undertaken training on the safe removal of ear wax and will use best practice procedures to minimise the risks and complications as already stated above. By agreeing to these terms and conditions you accept that you have read and understand the possible complications that may occur and agree that the clinician carrying out the procedure cannot be held responsible for them. I have read and understand the terms and conditions above and am willing to be bound by them. I also consent to any data including video otoscopic images, to be collected and stored for clinical reference. We do not share any personal data to third parties unless necessary for providing healthcare service. Please tick to confirm you have read and agree to the terms and condtions. *

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Thank you for completing the consent form. Once reviewed, we will then confirm your appointment.