Free Microsuction and Irrigation Ear Wax Removal Consent Form

To ensure the safe removal of wax or foreign bodies from your ear canal, it is essential for the clinician to be fully informed about any relevant health conditions. Please answer the following questions about your hearing health by selecting and completing the appropriate options.

Practice Details

Patient Details

Do you suffer from any condition that causes balance problems, vertigo attacks, or have you experienced dizziness, fainting, or any balance issues in the past 6 months?

Have you had any fluid discharge from your ear/s within the last 30 days?

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

Are you aware of, or suspect you may have or have had a perforated ear drum?

Which ear is it?

Have you tried to remove the wax yourself other than using ear drops?

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

Which surgical operation(s) did you have?

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

Are you using any antiplatelet or anticoagulant blood thinners (E.g. Warfarin)?

Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?

Which ear(s) do you have tinnitus in?

Have you had wax removed from your ears previously?

Do any of the following apply to you?

Are you aware of any reason as to why you should not proceed with microsuction or irrigation?

Does the signature above belong to the patient?