Micro Suction Ear Wax Removal Consent

Gender*

Male
Female

Do you have underlying conditions or offered a flu jab each year?*

Yes
No

Do you suffer from any condition that causes balance problems or vertigo?

Yes
No

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

Yes
No

Have you had any previous operations on your ears, nose or throat?

Yes
No

If YES, which ear?

Left
Right

Do you have a perforated ear drum?

Yes
No

If YES, which ear?

Left
Right

Have you tried to remove the wax yourself?

Yes
No

Have you suffered from any pain in your ears within the last 30 days?

Yes
No

Are you currently seeing an ENT consultant or receiving any treatment regarding your ears?

Yes
No

Are you using anticoagulants, eg Warfarin?

Yes
No

Are you aware of any reason as to why you should not proceed with micro suction?

Yes
No

Have you had wax removed from your ears previously?

Yes
No

Hearing Screen – For over 55s, we encourage you to book our free hearing test, should you answer YES to the following: Do you experience problems with hearing in social environments?

Yes
No

Do your family comment on your hearing?

Yes
No

Do you find you are turning up the TV?

Yes
No

I am the:*

Patient
Parent
Guardian

We’d be very grateful if you would let us know how you discovered our clinic by ticking one of the boxes below:*

PRIVATE MICRO SUCTION WAX REMOVAL CONSENT

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