Ear Irrigation Consent Form - Bulk Billed

  • Ear Irrigation Consent Form

  • Has this patient had their ears irrigated or 'syringed' previously?*

  • The patient named above has complete wax blockage of either one or both of their ear canals. 

    Recommendation: The doctor has recommended treatment with ear drops to soften the wax blockage, and review approximately 1-2 weeks later to assess whether the ear is still blocked and ear irrigation (aka ‘syringing’)  is needed. If required, the ear irrigation procedure will be performed at the nursing home by Elder Medical's doctors & suitably trained Medical Practice Assistants.

     

  • General Information

    Ear Wax Removal (Irrigation) Procedure

  • About Ear Wax:

    Ear wax is a very important substance.  It cleans, lubricates and prevents infection in the ear canal. As we get older, ear wax gets drier and the natural cleansing action breaks down causing it to block the ear at times. It is not necessary to remove wax unless it is causing a problem such as muffled hearing.  

    Irrigation Procedure:

    The procedure involves gently squirting warm water into the ear canal via a nozzle.  The water dislodges the wax, which will then come out of the ear.  Most patients describe it as an odd feeling; but it shouldn’t hurt. The procedure should not be performed if there is an infection present, if there is a history of perforation (burst ear drum) or if there have been side effects when performed previously. Ear wax removal procedures are performed at the nursing home by Elder Medical's doctors & suitably trained Medical Practice Assistants. 

    Possible complications of syringing: 

    • Occasional:  infection of the ear canal, transient pain, transient tinnitus. 
    • Rare: Chronic tinnitus, transient vertigo, and a perforated ear drum. 

    How long does the procedure take?

    Between 15 - 45 minutes.  

    How much does it cost?

    There is no out of pocket cost for this procedure currently. Dr Molloy will "bulk bill" Medicare for the associated consultation with no additional fee charged. 

  • Declaration of Consent

    Ear Wax Irrigation Procedure
  • I consent for ear syringing to be performed for the patient named above as deemed necessary by the treating doctor.*
  • This form can serve as continued consent if future ear irrigation procedures are needed again.*
  • I consent for the doctor to 'bulk bill' this procedure according the the appropriate time-based Medicare attendance item (no out of pocket fee).*
  • Should be Empty: