Suction Ears - Resident Home Visit Referral Form

Resident Home Visit - Consent Form
Resident Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resident Full Name:*

First NameLast Name
Patient Preferred Name:
Date of Birth*

MonthDayYear
Date
Room / Unit Number:
Referral Details:
Reason for Referral:

Excessive Ear WaxHearing Loss / ImpairmentEar Discomfort / PainTinnitusUnable to have irrigation / water in earsGP has requestedAudiologist has requestedOther
If Other selected, please specify:
Additional Information / Comments:
Consent for Microsuction Ear Wax Removal:

Suction Ears provides safe and effective microsuction ear wax removal services. Our team of accredited audiologists will visit the nursing home to perform the procedure. Please review the following information carefully and provide your consent for the service.

1.Service Description

• Microsuction is a procedure that involves using a small suction device to remove earwax under direct vision. The audiologist will use specialized binocular glasses fitted witha bright light or a microscope to view the ear canal clearly during the procedure.

2.Benefits of Microsuction

• Safe and Gentle: Minimizes the risk of damage to the ear canal or eardrum.
• Effective: Thoroughly removes ear wax, improving hearing clarity.
• Quick Procedure: Typically completed within 15-30 minutes.

3.Possible Risks and Discomforts

• Mild discomfort or tickling sensation during the procedure.
• Rare risk of temporary dizziness or ear canal irritation.
• Possible minor bleeding if the ear canal is very sensitive.

4. Resident Consent

By signing below, I consent to the microsuction ear wax removal procedure. I understand the nature of the procedure, its potential benefits, and associated risks. I understand that I am able to pause the procedure at any time should I feel discomfort and have the opportunity to ask questions at any time pre-post and during the procedure.
Resident or Legal Guardian Name:
Signature

Powered by Jotform SignClear
Resident Representative / Supervisor Name:
Signature

Powered by Jotform SignClear
6. Financial Responsibility

Please indicate who will be financially responsible for the procedure. The responsible party will be invoiced for the service following the appointment.
Responsible Party
Name of Responsible Party:
Relationship to Resident (if applicable):
Contact information:
Date

MonthDayYear
Date
Thank you for referring your patient to us for microsuction ear wax removal.

Our team of audiologists look forward to caring for your patient's ears and will see them shortly for their appointment.

If you have any questions, please email us at info@suctionears.com.au or contact us on 1300 327 349 (1300 EAR FIX).
Should be Empty:

Resident Home Visit - Consent Form

Consent for Microsuction Ear Wax Removal:

1.Service Description

2.Benefits of Microsuction

3.Possible Risks and Discomforts

4. Resident Consent

6. Financial Responsibility