Sign Form

The purpose of microsuction and irrigation is to remove any wax present within the ear canal. To ensure this process is carried out safely, it is important that the clinician is made aware of anything which may have a bearing on the procedure.

Please answer the questions regarding your hearing health, ticking the relevant box:

1A. Do you suffer from any conditions which causes balance problems or a Vertigo attack?*

YesNo

1B. If Yes to 1A, please state any condition(s).*

2. Have you had a vertigo attack within the last 30 days?*

YesNo

3. Have you suffered with any pain in your ears in the last 30 days?*

YesNo

4A. Do you have a perforated ear drum?*

YesNo

4B. If Yes (to 4A) which ear(s)?*

LeftRight

4C. If Yes (to 4B) roughly when did this occur? *

Date

5. Have you tried to remove the wax yourself other than using ear drops?*

YesNo

6. Are you currently under an ENT consultant or receiving any treatment to your ears?*

YesNo

7A. Have you had any previous operations on your ears, nose or throat?*

YesNo

7B. If Yes (to 7A) which ear(s)?*

LeftRight

7C. If Yes (to 7B) roughly when did this occur? *

Date

8. Are you using any anti-coagulants e.g. Warfarin*

YesNo

9. Have you previously had wax removed from your ears?*

YesNo

10. Do you have persistent Tinnitus (usually a ringing or buzzing noise in the head or ears)?*

YesNo

11A. Do any of the following apply to you: Impaired Immune System - Diabetes, Cancer, Chemotherapy or Radiotherapy?*

YesNo

11B. If Yes to 11A please select the conditions or treatments that apply to you:*

12. Have you or anyone in your household had Covid or any other infections/illness in the past 7 days that may require the use of PPE today?*

YesNo

13A. Are you aware of any reason why you should not proceed with Microsuction or Irrigation?*

YesNo

14B. If Yes to 13A please state your reason below*

Anglia Ear Care Solutions is governed by these terms and conditions.

Wax removed via micro suction and irrigation is considered safer than other methods such as syringing.

The wax removed will be carried out by a trained clinician working to the protocols set out for Aural Micro Suction and irrigation procedures.

Complications of ear wax removal with Micro Suction are uncommon however, possible difficulties, side effects and material risk inherent in the procedure include but are not limited to: Incomplete removal of ear wax requiring a return visit (for severely impacted wax), minor bleeding, discomfort, ringing in the ear (tinnitus), perforation of the ear drum and hearing loss.

Complications from irrigation are failure of wax removal requiring a return visit (for severely impacted wax), an otitis externa (infection) perforation of the tympanic membrane (ear drum), damage to the outer ear canal, discomfort, pain, bleeding (usually self - limiting), nausea, vomiting and vertigo resulting from temperature variations of the irrigating. Instrumentation risks can include infection, trauma to the ear canal and perforation to the eardrum if the patient moves.

To ensure the risk of complication is minimal, it is essential that accurate past medical history is supplied to the clinician. In addition, it is important that the patient remains relatively still throughout the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding. By agreeing to these terms and conditions you accept that you have read and understood the possible complications that may occur and agree that Anglia Ear Care Solutions hearing specialist cannot be held responsible for them.

I have read and understood the terms and conditions above and am willing to be bound by them and consent to treatment.

Name*

First NameLast Name

Date*

Date

Signature*