Ear Wax Removal Consent Form

Ear Wax Removal Consent Form Dorking

Complete prior to each visit.
Please note we have moved to 'Frith Pharmacy'

38-40 South Street, Dorking - adjacent to Waitrose
Name*

FirstLast
Email
Optional - but you receive a copy, and it helps us find your records
GP Surgery Name
PRACTICE NAME (not Doctor)
Have you had ear wax removed before?*

Yes - irrigation / syringingYes - microsuctionYes - both the aboveNo
How did you hear about us?

Repeat customerInternet searchLocal GPRecommended - by friend / familyRecommended by other company
Please tick ALL applicable options below
Ear Related Problems:*

1) Previous problems with microsuction?2) Previous problems with irrigation?3) Ear pain - within last 90 days?4) Ear infection (confirmed) - within last 90 days?5) Ear discharge - within last 90 days?6) Recent dizziness - within the last 90 days?7) Ongoing history of severe dizziness8) Troublesome / prominent tinnitus? (state if affected by loud noise)9) Existing ear perforation? (known or suspected)10) Previous history of ear perforations (now healed)11) Any operations on the ears? (including grommets)None of the above
Full Details:
Can write 'same as previous form'
Other Medical Related Issues:*

12) Anticoagulant medication? (e.g. blood thinners)13) Unable to keep head still14) Recent radiotherapy on head or neck? (can thin skin lining)15) Cleft palate (repaired or not) ?16) Recent facial tingling?17) Recent metallic taste sensations?18) Impaired immune system? (e.g. diabetes, HIV, HEP B)None of the above
Full Details:
Can write 'same as previous form'
Other comments or requests:
eg. wheelchair access required
Contra-indication microsuction
Contra-indication irrigation
Special precaution microsuction
Special precaution irrigation
Check for cholesteatoma
Signature

Clear
Age of child
NO CHILDREN - we cannot treat children - please cancel your appointment if you booked for a child under 18, and see note below.
Note:
Our current prices are shown here

TERMS OF SERVICE:

Your ear wax removal will be carried out by a trained clinician working to industry standard protocols. Wax removal may be done via micro-suction, irrigation /syringing, and / or dry tool extraction – whichever the clinician deems most appropriate based on the wax you present and your answers to this form.

Incidents during ear wax removal are uncommon, however:

Minor complications that can occur which are deemed acceptable include: minor nicks or scratches to the ear canal which can also lead to minor bleeding, soreness, mild discomfort and short-term ringing in the ear (tinnitus). To minimise such risk please remain still, and immediately notify the clinician of any physical discomfort, or sensitivity to noise level. Clients should also inform the clinician of any discomfort or likely sudden movements, for example if likely to sneeze or cough.

More serious / long term risk can occur if the client does not (or cannot) remain adequately still, or notify the clinician of discomfort (physical and or noise). Do not tolerate discomfort.

All equipment is sterilised or is single use only to keep infection risk to a minimum; however, there is always a risk that infection can set in once the client leaves the premises. Please contact the clinician for a free follow-up visit should you experience any discomfort, swelling, or discharge, etc.

The CE marked micro-suction unit is designed to remove fluids from the airway or respiratory system and infectious materials from wounds. It has been adapted for aural micro suction and following risk assessment this has been approved by Barry Fenton professional indemnity insurance brokers. Representatives of Crystal Hearing are insured for professional indemnity with Barry Fenton Insurance Brokers - our certificates can be presented at any time.

CHILDREN - We cannot treat children due to UK law. Please contact Aston Hearing. If you attend clinic with a child you will be liable for the clear ear fee of £35 for the appointment time, but we cannot treat them.

PRIVACY STATEMENT - Your personal details will not be used for marketing whatsoever. By clicking to these terms you do agree that we may email you this form, we request a review off you, and that we may email you to inform you when the office is likely to be closed for staff holidays so that you can book future appointments.

www.crystalhearinguk.co.uk/privacy-policy/
Should be Empty:

Ear Wax Removal Consent Form Dorking

Please note we have moved to 'Frith Pharmacy'