--- title: Free Microsuction and Irrigation Ear Wax Removal Consent Form description: Complete the Microsuction and Irrigation Ear Wax Removal Consent Form to ensure a safe and effective procedure. image: https://earhealthsolutions.co.uk/hubfs/wax-removal-consent-form.jpg --- - [About](https://earhealthsolutions.co.uk/about) - [Services](https://earhealthsolutions.co.uk/) - [Audiology Integration](https://earhealthsolutions.co.uk/audiology-integration) - [Rebranding & Digital Presence](https://earhealthsolutions.co.uk/rebranding-digital-presence) - [Staff Training & Recruitment](https://earhealthsolutions.co.uk/staff-training-recruitment) - [Resources](https://earhealthsolutions.co.uk/) - [Blog Posts](https://earhealthsolutions.co.uk/resources/tag/blog-post) - [Patient Management Tools](https://earhealthsolutions.co.uk/resources/tag/patient-management-tool) - [Press Releases](https://earhealthsolutions.co.uk/resources/tag/press-release) - [See all Resources](https://earhealthsolutions.co.uk/resources) [Contact Us](https://earhealthsolutions.co.uk/contact) × ## Terms of Service Microsuction Earwax Removal is a suction that gently vacuums the earwax with the assistance of Headloups or an Endoscope. Low-pressure irrigation may be used to soften the earwax and to assist micro-suction. Manual ENT tools can be used to gently pry out earwax or foreign objects. Complications of ear wax removal with micro-suction, low-pressure irrigation and manual tools are uncommon; however possible complications, side effects and material risks inherent in the procedure include but are not limited to: incomplete removal of ear wax requiring a return visit (for severely impacted wax), minor bleeding, discomfort, ringing in the ear (tinnitus), perforation of the eardrum and hearing loss. To ensure the risk of complication is minimal, it is essential that accurate past medical history is supplied to our clinicians. In addition, it is important that the patient remains relatively still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding.  The CE-marked suction unit removes fluids from the airway or respiratory support system and infectious materials from wounds and has been adapted for aural micro-suction. The suction unit is being used off-label. By agreeing to these terms of service you agree that images or videos of the wax removal may be used for marketing purposes. By agreeing to these terms of service you accept that you have read and understand the possible complications that may occur and agree that the clinic, or any of its employees, cannot be held responsible for them. I have read and understood the terms and conditions above and am willing to be bound by them. # 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 Practice Name: Practice Address: Practice Email Address (PDF will be sent here): ## 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? Yes No Ear irrigation must not be performed if you have had balance issues, vertigo, dizziness, or fainting in the past 6 months. Inform the clinician immediately to discuss alternative removal methods. Have you had any fluid discharge from your ear/s within the last 30 days? Yes No Have you suffered any pain in your ears within the last 30 days? Yes No Pain Level: Mild Significant Excruciating Are you aware of, or suspect you may have or have had a perforated ear drum? Yes No Which ear is it? Left Right Both How long ago did this occur? Have you tried to remove the wax yourself other than using ear drops? Yes No Have you had any surgical operations on your ears, nose, or throat? Yes No Which surgical operation(s) did you have? Left Ear Right Ear Nose Throat How long ago did you have the operation(s)? If the surgical operation was performed within the past 6 months, ear wax removal must not be performed. Please inform the clinician immediately. Are you currently under an ENT Consultant or receiving any treatment regarding your ears? Yes No Treatment Details: Are you using any antiplatelet or anticoagulant blood thinners (E.g. Warfarin)? Yes No Blood Thinner Details: Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)? Yes No Which ear(s) do you have tinnitus in? Left Right Both Have you had wax removed from your ears previously? Yes - Microsuction Yes - Other No Do any of the following apply to you? Impaired immune system (e.g., diabetes, cancer, HIV, HEP B, MRSA) Radiotherapy on the head/neck Recent metallic taste sensations Recent facial tingling or numbness Provide details regarding the above: Are you aware of any reason as to why you should not proceed with microsuction or irrigation? Yes No Please discuss this with your clinician before signing this form. Patient First Name: Patient Last Name: Does the signature above belong to the patient? Yes No Signee First Name Signee Last Name Reason for signee not being the patient Patient Signature: Clear Signature Date of Signature: I have read and understood the terms of service and am willing to be bound by them. Submit **Address:** 24b The Broadway, Addlestone, KT15 3HA, United Kingdom **Email:** info@earhealthsolutions.co.uk **Phone:** +44 (808) 196-1200 ## Services - [Audiology Integration](https://earhealthsolutions.co.uk/audiology-integration) - [Rebranding & Digital Presence](https://earhealthsolutions.co.uk/rebranding-digital-presence) - [Staff Training & Recruitment](https://earhealthsolutions.co.uk/staff-training-recruitment) ## About - [About Us](https://earhealthsolutions.co.uk/about) - [Resources](https://earhealthsolutions.co.uk/resources) - [Privacy Notice](https://earhealthsolutions.co.uk/privacy) - [Cookies](https://earhealthsolutions.co.uk/cookies)  (Edit Consent) - [Terms of Service](https://earhealthsolutions.co.uk/terms-of-service) - [Accessibility Statement](https://earhealthsolutions.co.uk/accessibility) - [Sitemap](https://earhealthsolutions.co.uk/sitemap.xml) ## Talk to us - [Contact Us](https://earhealthsolutions.co.uk/contact) - [info@earhealthsolutions.co.uk](mailto:info@earhealthsolutions.co.uk) - - - - - © Ear Health Solutions Limited. All rights reserved. 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