C. E. Micro Suction Wax Removal Consent-Gerry Durkin

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. Please answer these questions regarding your ear health, by ticking the relevant boxes:

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

Yes

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

Yes

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

Yes

Are you aware if you have a perforated ear drum?

Yes

If “Yes”, which ear?

Left

Right

How long ago did this occur? Year(s)

Have you tried to soften or remove the wax yourself using drops?

Yes

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

Yes

If “Yes”, which ear?

Left

Right

How long ago did this occur? Year(s)

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

Yes

Are you using anticoagulants, e.g. Warfarin?

Yes

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

Yes

Have you had wax removed from your ears previously?

Yes

Ear wax removal via micro suction is considered safer than other methods such as syringing. The procedure will be performed by a qualified trained clinician following guidelines written by The Hearing Lab & The British Society of Audiology. Complications of ear wax removal with micro suction 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 ear drum and hearing loss.

To ensure the risk of complication is minimal, it is essential that accurate past medical history is supplied to the 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 is to remove fluids from the airway or respiratory support system and infectious materials from wounds and has been adapted for aural micro suction.

By agreeing to these terms and conditions you accept that you have read and understand the possible complications that may occur and agree that the clinical ear care specialists carrying out today’s procedure cannot not be held responsible for them.

I have read and understood the terms and conditions above and am willing to be bound by them.

First Name

Last Name

Date Of Birth

Date

Your Signature