Consent Form. - Peninsula Ear Care

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

First line and Postcode only needed

Date of birth

Date of Birth

GP Surgery

Appointment Date / Time *

Date

Time

What service are you booking for? *

Assessment & Wax Removal

Have you had severe difficulties in the past with microsuction or severe dizziness *

Yes
No

Are you able to keep your head still without sudden movements? *

Yes
No

Theoritical risks. There is a rare but a possibility of damage to the ear drum. This is highly unlikely, but you do need to keep your head still for the procedure. If you need to move, cough, please alert the clinician and they will pause until you're ready. Bruising to the ear canal, this doesn't happen often, but is a possibility, and it will be minor and superficial, should this occur. Is more likely to happen if the wax is adhered to the ear canal wall, or you have exceptionally narrow canals, therefore please use olive oil prior to the appointment. The smallest appropriate specula will be used to hold your ear canal open for the procedure. The treatment may be noisy, especially as we get nearer the ear drum. The procedure has the potential to induce further tinnitus in some patients, especially if you already suffer from it, but it is usually only for a short time. Some patients may experience the need to cough during treatment (due to stimulating a superficial nerve in the ear canal). This will be transient, and treatment will be paused until you are ready to proceed. *

I Agree, and accept this risk.

I understand that Peninsula Ear Care is not part of the NHS, and is a private company. Therefore, charges apply for consulation, and treatment. These are available on the website. *

I agree to pay for this service.

General notice: I understand that having microsuction is not guaranteed to result in better hearing or improvement of symptoms, I understand the above and have been given an opportunity to ask questions *

I accept and understand.

What Symptoms have you had, and for how long? *

Do you have pain now? *

Do you have any discharge from the ear(s) now? *

Do you have any previous medical issues with your ears?

Have you used any self care treatments to soften or remove ear wax in the last week?

Olive Oil
Earex
Sodium Bicarbonate
Other

Impressions

What are you having impressions made for?

Other – please give details

Review Appointment information

Please state if there are any changes since your last appointment? *

Please sign and date below to consent to Peninsula Ear Care carrying out your Treatment *

Name and Date, will be taken as electronic signature.

How did you hear about Peninsula Ear Care?

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.