Consent Form Ear Wax Removal Name * First Name Last Name Email Phone (###) ### #### PROCEDURE: The ear is viewed through a microscope. This allows for wax to be removed using various instruments such as a suction probe and ENT micro-instruments (e.g. ear hook, jobson horne, crocodile forceps). A suction machine is used 'off- label' for suction since there are no suction machines currently available for the intended use of ear (aural) suction. It is instructed you remain as still as possible during the procedure. If at any stage you wish the procedure to stop please notify the Audiologist immediately. Read Have you had ear wax removal before? Yes No Was your last appointment within the last 5 years? Yes No Have you had any complications with ear wax removal before? Yes No Do you struggle with tinnitus? Yes No Are you currently suffering from vertigo or dizziness? Yes No Have you had any operations for your ears, nose, or throat? Yes No Are you currently taking any blood thinning medication? Yes No Do you suffer with vasovagel syncope, or fainting episodes? Yes No BENEFITS: Ear wax removal can result in the improvement of related symptoms to impacted ear wax such as hearing loss, earache, discomfort, blocked ear, tinnitus, vertigo, occlusion, itchiness and whistling of hearing aid. However, successful ear wax removal does not always result in the improvement of possibly related symptoms due to the cause being as a result of other underlying pre-existing health and/or ear-related conditions. Read RISKS: Associated risks and side-effects include but are not limited to: tinnitus (a ringing type noise in the ear) or increased tinnitus if already experiencing, pain, bleeding, bruising, trauma to ear canal, perforation of the eardrum, ear infection, ear discharge. Read STATEMENT OF PATIENT/PARENT/GUARDIAN: The patient is advised to ask if they have any further questions, or for repetition of any information provided. They agree to the procedure or course of treatment described on this form to take place. They understand that there is no guarantee that the procedure described on this consent form will be successful or result in the improvement of possibly related symptoms whether successful or not. They understand the procedure, intended benefits and risks described on this consent form. Read Digital Signature (Verbal Consent Obtained to Proceed) By signing, you agree to the terms as stated above Thank you!
