Ear Wax Removal Consent Form

Name *

First

Last

Address *

Date of Birth *

Home Phone Number *

Mobile Phone Number *

Email Address *

Do you suffer any conditions that causes balance problems or vertigo attacks? *

Yes
No

If Yes, have you had a vertigo attack within the last 30 days? *

Yes
No

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

Yes
No

Do you have an existing perforated ear drum? *

Yes
No

If ‘Yes’ which ear?

Left
Right

When did this occur?

Have you had a perforated eardrum which has since healed? *

Yes
No

If ‘Yes’ which ear?

Left
Right

Have you had any operations on your ears? *

Yes
No

If ‘Yes’ which ear?

Left
Right

When did this occur?

Do you have a cleft palate? *

Yes
No

Are you diabetic? *

Yes
No

Are you currently having radiotherapy? *

Yes
No

Do you have Hepatitis / HIV? *

Yes
No

Do you have tinnitus? *

Yes
No

If ‘Yes’ which ear?

Left
Right

Is it sound sensitive tinnitus?

Yes
No

Are you currently under an ENT Consultant or receiving any treatment regarding your ears? *

Yes
No

Are you using anticoagulants – blood thinning drugs, eg Warfarin, Asprin? *

Yes
No

Have you tried to remove the wax yourself? *

Yes
No

If 'Yes', How did you try to remove the wax?

Have you had ear wax removed from your ears previously? *

Yes
No

If Yes, when?

I agree to my GP being advised of the outcome of the Micro Suction Procedure *

Yes
No

GP Name

GP Address

Your details will NEVER be passed to third parties. I would like to receive personalised marketing communication regarding exclusive news and special offers from Lisa Graham Hearingcare and the latest innovations in hearing technology. I consent to receiving this via the methods below: (tick as appropriate)

Email
Mail
Phone
SMS

You can update your contact preferences at any time by the following methods: www.lisagrahamhearingcare.co.uk, email info@lisagrahamhearingcare.co.uk, phone 07421 707660. Your contact preferences will be updated within 1 month of receipt of your request.

Lisa Graham Hearingcare is governed by these terms and conditions. Following a discussion of the above information, your ears will be examined, and wax removed using the safest and most appropriate methods given your medical history and the nature of wax discovered. This may be via: 1) Microsuction – Effectively a vacuum to clear debris or wax from the ear canal while being viewed through magnifying Loupes. The CE marked suction unit is to remove fluids from the airway or respiratory support system and infectious materials from wounds and has been adapted for aural micro suction. 2) Instrumentation - For gentle removal of wax close to the ear canal entrance may be used. The instruments are carefully inserted into the ear canal to clear the debris or wax while being viewed closely through magnifying Loupes. 3) Irrigation / Spray Wash - The ProPulse water irrigator unit is CE-marked and has been designed specifically for wax removal may be used as well as the Bionix Spray Wash. Low pressure, pulses of body temperature (37˚C) flush out the ear canal. The Wax Removal Specialist has undertaken training in debris and wax removal and will use best-practice procedures to minimise any risk of harm and complication are not common. However, even when performed with the upmost care, there is a small risk of damage or infection to the skin of the ear canal or eardrum. Furthermore, the procedures of microsuction and water irrigation can be noisy and may cause a shift in your hearing thresholds (generally temporary) or start/aggravate any existing tinnitus. There is also the risk of temporary dizziness or discomfort. In certain instances, olive oil may be used during the procedure, unless there is a known sensitivity. It is important to remain still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding. Finally, where it is not possible to remove the wax, you may be advised to use further treatment with olive oil or sodium bicarbonate solution and book a further visit. By agreeing to these terms and conditions you accept that you have read and understand the possible complications that may occur and agree that Lisa Graham Hearingcare wax removal specialists, or any of its employees cannot be held responsible for them. I have read and understood the terms and conditions above and I am willing to be bound by them. *

I Agree