Microsuction & Irrigation Ear Wax Removal
To safely remove any wax or foreign bodies presentwithin the ear canal, it Is Important that the clinician is made fully aware of anything which may have a bearing onthe procedure. Please answer the following questionsregarding your hearing health by ticking and completing the relevant boxes:
Do you suffer from any condition that causes balanceproblems or vertigo attacks?*
Yes
No
Have you had any fluid discharge from your ear/swithin the last 30 days?*
Yes
No
Have you suffered any pain in your ears within thelast 30 days?*
Yes
No
Are you aware of, or suspect you may have or havehad a perforated ear drum?*
Yes
No
Have you tried to remove the wax yourself otherthan using ear drops?*
Yes
No
Have you had any surgical operations on your ears,nose or throat?*
Yes
No
Are you currently under an ENT Consultant orreceiving any treatment regarding your ears?*
Yes
No
Are you using any antiplatelet or anticoagulantblood thinners?* (E.g. Warfarin)*
Yes
No
Do you have persistent tinnitus (usually a ringingor buzzing noise in the head or ears)?*
Yes
No
Have you had wax removed from your ears previously?*
Yes - microsuction
Yes - other
No
Do any of the following apply to you?
Impaired immune system- diabetes, cancer, HIV, HEP B, MRSA, etc.
Radiotherapy on the head/neck.
Recent metallic taste sensations
Recent facial tingling or numbness
Any details regarding the above
Are you aware of any reason as to why you should not proceed with microsuction or irrigation?
*
Yes
No
Patient* : Name and Surname
Patient Signature* : (or signature of Parent if under 16, guardian or attorney if appropriate)
Does the signature above belong to the patient ?
*
Yes
No
Date of Signature
*
-
Month
-
Day
Year
Date
This form is completed to the best of my knowledge.
Consent Terms* : I have read and understood the terms of service and am willing to be bound by them
Yes
No
SUBMIT FORM
to info@earwaxremovalheysham.co.uk
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