Seattle, WA - OCN Appointment Request Form

What sparks your interest in professional ear cleaning today?*

I'm dealing with inner ear discomfort like itchiness or painI think impacted earwax might be affecting my hearingI wear hearing aids and earwax buildup is often a problemI love the feeling of having clean and refreshed earsI think I have earwax buildup and need to take care of itI'm all about staying healthy and this will help me feel great!

How do you currently handle your ear cleaning needs?*

Cotton swabs (e.g. Q-tips) or similar itemsOver-the-counter earwax removal productsRegular visits to my healthcare providerI haven't done much to clean my ears so far

My ear health challenges impact me in the following ways:*

The itchiness and discomfort becomes really bothersomeI feel self-conscious about ear cleanliness in social settingsIt's a challenge to clean my ears properly on my ownStruggling to hear clearly affects how I communicate at home or workMy ear health concerns are a bit annoying but don’t really hold me backI don't have ear health challenges that bother me

Do any of the following apply to you?*

I have had ear tubes within the last 2 yearsI have had an eardrum perforation in the past 3 monthsThe person seeking treatment is under the age of 18None of the above

Have you interacted with professionals regarding your ear health?*

Primary Care ProviderUrgent Care CenterEar Nose and Throat (ENT)Audiologist/Hearing ClinicAlternative HealthcareNot yet - but I'm excited for this!

Which of the below options best describes you?*

Results oriented - I'm quick to answer and make fast decisionsAnalytically oriented - I always study issues and gather factsCooperation oriented - I always find common ground with othersSocially oriented - I value my friends' opinions and online reviews

The FDA-cleared OtoSet^® Ear Cleaning System takes a few minutes to set up and only about 10 minutes for the ear cleaning itself. Your clinician will explain everything beforehand and is happy to answer any questions you have!

How excited are you about getting your ears cleaned?*

Not very interested at the momentEnthusiastic - but I have some questionsNot that excited - but I really need itReady to schedule my appointmentReady to get in the car right now!

Let's find out if you qualify for an ear cleaning!

We will reach out to you to confirm qualification and offer an appointment.
First Name*
Last Name*
Email Address*
This allows us to send you qualification info
Phone Number*
This allows us to send you qualification info
Zip Code*

Street Address

Street Address Line 2

CityState / Province

This allows us to find the closest clinic to you
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By submitting this form you agree to the following:
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