MICRO SUCTION WAX REMOVAL CONSENT
VALE HEARING HEALTH CARE
Full Name
*
First Name
Last Name
Address
*
House Name / Number
Street
Town / City
County
Post Code
Phone Number
*
Email Address
*
Confirmation Email
Email Addresses Must Match
Date Of Birth
*
Please Fill This Section In the Format As Example 31/12/1975
PLEASE ENTER YOUR GP / DOCTORS SURGERY ADDRESS / TOWN
*
How Did You Hear About Our Services?
*
Please Select
Google
Facebook
Local Advert / Business
Doctors Surgery
Hospital Referral
Other
General And Medical Information
Please Fill All Questions Below Honestly And To The Best Of Your Knowledge
Do You Suffer From Any Condition That Causes Balance Problems Or Vertigo Attacks?
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Yes
No
Have You Had Any Vertigo Attacks In The Last 30 Days?
Yes
No
Have You Suffered Any Pain In Your Ears In The Last 30 Days?
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Yes
No
Are You Aware Of, Or Suspect You May Have A Perforated Ear Drum?
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Yes
No
If Suspected Perforated Ear Drum is it Left, Right Or Both?
Left
Right
Maybe Both
If Suspected Perforation Please Give Details Of How Long You Think This Has Been Occurring.
Do you Experience Any Tinnitus Noises In Your Ears?
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Yes
No
Have You Had Any Previous Operations On Your Ears Nose Or Throat?
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Yes
No
Ears, Nose Or Throat Operations
If You Answered yes To The Above Question Please Give Full Details e.g Which Ear/ s and How Long Ago
Are You Currently Under An ENT ( Ears, Nose, Throat Consultant )Or Receiving any Treatment Regarding Your Ears?
Yes
No
Are You Using Any Anticoagulants ( Blood Thinning)? eg Warfarin / Aspirin / Apixaban / Rivaroxaban / Heparin / Edoxaban ?
Yes
No
If Yes To Anticoagulants Please give full information below
Are You Aware Of Any Reason Why You Should Not Proceed With Microsuction?
*
Yes
No
Explain Your Reason Why You Might Think You Should Not Proceed To Micro Suction?
Have You Had Wax Removed From Your Ears Lately?
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Yes
No
If Yes To Wax Removal Lately Please Answer
Within 3 Months
Within 6 Months
Within 12 Months
TERMS AND CONDITIONS
PLEASE READ THE TERMS AND CONDITIONS BEFORE SUBMITTING YOUR APPLICATION
Please Enter Full Name Of Guardian If Patient Is Under The Age Of 18 Years Old
Are You Acting On Behalf Of The Potential Patient?
*
Yes
No
If Yes Enter Your Full Contact Details And Address Below. Please Mention Your Legal Entitlement To Act On The Behalf Of The Potential Patient.
Please verify that you are human
*
Submit
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