Ear Wax Removal Consent Form

Patient Name

First NameLast Name

Appointment Date

Date

The purpose of micro suction is to safely remove any wax or foreign bodies present within the ear canal. To ensure this process is safely carried out it is important that the clinician is made aware of anything which may have a bearing on the procedure.

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

YesNo

Have you had a vertigo (Rotational Dizziness) attack within the last 30 days?

YesNo

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

YesNo

Do you have a perforated ear drum?

YesNo

Have you tried to remove the wax yourself?

YesNo

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

YesNo

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

YesNo

Are you using anticoagulants (Blood thinning medication), e.g. Warfarin?

YesNo

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

YesNo

Have you had wax removed from your ears previously?

YesNo

Patients Signature

Clinicians Signature

Date Signed

Date