Micro Suction Consent

Full Name*

First NameLast Name

Address*

House Name / Number

Street

Town / CityCounty

Post Code

Phone Number*

Email Address*

Confirmation EmailEmail 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?*

Do You Suffer From Any Condition That Causes Balance Problems Or Vertigo Attacks?*

YesNo

Have You Had Any Vertigo Attacks (sensations of the room spinning) In The Last 30 Days?

YesNo

Have You Suffered Any Persistent Pain In Your Ear/s In The Last 30 Days?*

YesNo

Have you had any blood or fluid discharge from your ear/s within the last 30 days?*

YesNo

Are You Aware Of, Or Suspect You May Have A Perforated Ear Drum?*

YesNo

If Suspected Perforated Ear Drum, is it Left, Right Or Both?

LeftRightMaybe Both

If Suspected Perforation Please Give Details Of How Long You Think This Has Been Occurring.

Do you Experience Any Tinnitus Noises (ringing, buzzing, hissing etc) In Your Ears?*

YesNo

Have You Had Any Previous Operations On Your Ears Nose Or Throat?*

YesNo

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?

YesNo

Are You Using Any Blood Thinning Medication (anticoagulants)? e.g. Warfarin/Aspirin /Apixaban/Rivaroxaban/Heparin/Edoxaban/Clopidogrel?

YesNo

If Yes To Anticoagulants Please give full information below

Have you been diagnosed with any of the following?

Have You Had Wax Removed From Your Ears In The Last 12 Months?*

YesNo

If Yes To Wax Removal Lately Please Answer

Within 3 MonthsWithin 6 MonthsWithin 12 Months

Are You Aware Of Any Reason Why You Should Not Proceed With Microsuction?*

YesNo

Explain Your Reason Why You Might Think You Should Not Proceed To Micro Suction?

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?*

YesNo

If Yes Enter Your Full Contact Details And Address Below. Please Mention Your Legal Entitlement To Act On The Behalf Of The Potential Patient.

MICRO SUCTION TERMS AND CONDITIONS

We are governed by these terms and conditions.

Wax removal via micro suction is considered safer than other methods. Complications of ear wax removal with micro suction 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 are turn visit (for severely impacted wax), minor bleeding, discomfort, ringing in the ear (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 our clinicians. In addition, it is important that the patient remains relatively 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 airway or respiratory support system and infectious materials from wounds and has been adapted for aural micro suction.

By agreeing to these terms and conditions you accept that you have read and understand the possible complications that may occur and agree that Vale Hearing Healthcare, or any of its employees, cannot be held responsible for them. I have read and understood the terms and conditions above and am willing to be bound by them.

Please enter the full name of guardian if the patient is under 18 years of age.

The guardian takes full responsibility that the patients application form is completed in full and correct. Details must be entered before the patient can receive any treatment.

If micro suction does not need to be performed, a consultation fee of £25 will be charged.

MICRO SUCTION WAX REMOVAL CONSENT

General And Medical Information