CONSENT FORM FOR EAR WAX REMOVAL
In order to check that it is safe to proceed you will be asked some questions about the health of your ears and general health. It is also necessary to carry out a detailed visual inspection of your ear/s and the wax present. If safe to do so, wax will be removed from your ear/s using the safest and most appropriate method for the quantity and consistency of the wax discovered.
Three methods of wax removal may be used, and these are sometimes used in combination:
Removal of wax deposits using manual extraction instruments
Fine hand-held instruments are inserted carefully into your ear and used to gently extract the wax from the ear canal
Wax removal using suction
Wax is removed from the ear by suction from the tube. This procedure can be noisy.
Wax removal using irrigation
A fine jet of water is gently circulated around the ear canal to loosen and remove the wax deposit. This procedure can also be noisy.
Your Audiologist is fully qualified and has undertaken training in wax removal and will use best-practice procedures to minimise any risk of harm. However, even when performed with the utmost care, there are risks involved in wax removal. These risks include:
damage to skin of the ear canal or the ear-drum during the procedure
infection of the ear canal or other ear structures following the procedure
temporary reduction in hearing
permanent reduction in hearing
temporary dizziness and (rarely) possible sickness or fainting
triggering of new tinnitus or temporary aggravation of existing tinnitus
temporary irritation to the throat, especially if already dry, tickly or sensitive
If the wax cannot be removed:
- Sometimes, depending on the amount and consistency of the wax and your own comfort, it may not be possible to remove all of the wax in one visit. If this situation occurs the Audiologist will stop the procedure and you will be advised to continue to use a wax softener for a few days and return to have the remainder removed. This will be at an additional reduced cost.
- Reasons to refer you to another professional or service.
Sometimes it may be necessary to reject you for this procedure. Most commonly this is because:
- Medical referral conditions have been discovered in the health screen prior to undertaking the procedure which indicate it is unsafe to proceed.
- It may also be necessary to refer you to a medical professional for further management following this procedure. Most commonly this is because:
- Evidence of a recent or previous infection has been discovered.
Evidence of recent or previous damage or disruption to the ear has been discovered.
- The wax removal procedure has made you feel unwell.
The wax is too difficult to remove without discomfort.
A foreign object has been discovered in the ear.
Aftercare:
- Please avoid using cotton buds/objects in or around your ears, and avoid directing water into your ears as this can push wax or naturally collected debris deeper and cause the ears to block again sooner. Most people need wax removal around every 6 months. Following this aftercare advice helps reduce the chance of ears blocking again too soon. If you notice symptoms returning, a new appointment would be required.
- All wax removal appointments are charged per visit.
The microsuction unit used is a CA-MI AS100 CE Marked Medical Device 'Off-Label'. The device has been specifically certified in compliance with EN 60601-1-11 "use in home-care".
Terms And Conditions
Cancellations
We require you to give 48 hours notice to cancel your wax removal session without incurring a charge. If your appointment is on a Monday, please cancel on Friday. If you provide less than 48 hours notice you may be charged the full cost of your session to cover the incurred costs.
Please note refunds are not given for same-day/urgent bookings
Non-attendance
If you fail to attend a session without giving any notice for that session you will need to pay for that session before booking any further sessions, unless we have an alternative arrangement in place.
Our Privacy Policy & Your Data Protection Rights
Confidentiality
Your wax removal session notes and personal information are kept securely. In certain circumstances, information, but not names, may be shared with other relevant health and medical professionals acting in that capacity. It is my legal duty to breach confidentiality if I have concerns that you or anyone else is at risk. If this occurs I will discuss it in the session along with any recommendations and document it in your notes.
As a fully accredited member of the Health Care Professions Council, I adhere to their ethical framework, guidelines, and code of conduct to ensure that you receive a professional and quality service.
Information we collect about you and how we use it
During your appointment, an assessment of your ear(s) health will be completed, and notes will be taken during sessions. The assessment and notes are used solely for the delivery of the audiological service to you.
Your rights
You have rights relating to the information I hold to verify the accuracy or to ask for them to be supplemented, deleted, updated or corrected. You have the right to request a copy of the information that I hold about you. If you would like a copy of some or all of your personal information, please send an email to hello@sussexearwaxremoval.co.uk. Information will be provided to you within 30 days.
We want to make sure that your information is accurate and up to date. You may ask me to correct or remove information you think is inaccurate. You have a right to request the transfer of your data to another individual or company.
You have the right to complain to the Independent Commissioner’s Office (ICO) if you think there is a problem with the way in which your data is being handled (see https://ico.org. uk/concerns/handling/).
How long we keep your information for - data retention
Your information is kept for the time necessary to provide the audiological service requested, however outside of this I will hold your details and session notes for the period dictated by the HCPC regulatory body.
Sharing of data
There may be times where your information needs to be shared with other healthcare professionals. I will explicitly ask your consent before doing so, and the data will be sent securely.
Please tick the box below to confirm:
I have read the information above and understand there are risks involved. I give my consent to allow the Audiologist to remove wax from my ear using the safest and most appropriate method for the amount and consistency of wax discovered.
I understand that the removal may take more than one visit and that each subsequent visit will incur a reduced charge. It may be necessary for me to refer you to a medical professional if any complications arise.
I agree to receiving emails about new services and clinic updates, with the option to unsubscribe within the email.
I agree to have the image of my ear recorded by a video otoscope before and after the procedure, and give my consent for those images to be stored digitally in my clinical notes.