Microsuction Consent Form

First name

Last name

Email

Date of birth

Day

Month

Year

Have you softened the wax before treatment?

Yes

No

Have you ever had wax removed previously?

Yes

No

Have you had an ear infection in the last 6 weeks?

Yes

No

Have you ever had a perforated ear drum?

Yes

No

Have you suffered with pain in your ears?

Yes

No

Did you consult your GP or other medical professional?

Yes

No

Do you suffer with tinnitus?

Yes

No

Do you suffer with dizziness?

Yes

No

Do you feel the wax is affecting your hearing?

Yes

No

Do you take anti-coagulant medication?

Yes

No

Additional information

I declare that the information I’ve provided is accurate and complete, and I have notified the ear care practitioner of any other factors that may affect my suitability for wax removal.

I understand and have been made aware of the small risks involved with wax removal.

I hereby give the ear care practitioner informed consent to perform otoscopy and micro-suction ear wax removal from my ears.

Signature

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