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Home
Procedures
Consent Form
Booking
Teeth Whitening
About Us
Contact Us
- FAQs

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MICRO SUCTION WAX REMOVAL CONSENT FORM

Micro suction removes 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.

Address

Postcode

Date Of Birth

Gender

Male

Female

Your Email

GP Practice (NHS) Name:

Location (town) of GP Practice:

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

Yes No

Please answer the following questions regarding your hearing health:

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

How long ago? (Years and months please)

Do you have a perforated ear drum?

Yes No

If YES, which ear?

Yes No

How long ago? (Years and months please)

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:

Internet GP Practice Waiting Room TV Screen Radio Recommended by friend / family Other

Book Your Appointment Now

ONLINE APPOINTMENT

It is crucial to take care of your ears and hearing health, and with advancements in recent technology, we can now offer a full ear care service in our clinics.

Our Services

Ear Health Screening
Single Ear Wax Removal
Both Ears Wax Removal
Home Visit Appointment
Otoscopy

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Tillow Barn Health & Wellbeing Roothill Lane Brockham Betchworth RH3 7AS
07555357375
info@earhealthspecialists.com

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