Ear Wax Consent Form

Ear Wax Removal Consent Form

In order to check that it is safe to proceed with wax removal it is important for you to answer the following questions. It is also necessary to detailed visual inspection of your ears and the wax present. If it is safe to do so the wax will be removed from the ear/s using the safest and method for the quantity and consistency of the wax discovered.

Wax removal using suction

Wax is removed from the ear by a suction tube, this can be noisy.

Wax removal using irrigation

A fine jet of water is gently circulated around the ear canal to loosen and remove the wax deposit, this can noisy. Removal of wax deposits using manual extraction instruments Fine hand-held instruments are inserted carefully into your ear and used to  wax from the ear canal.

If the wax cannot be removed

Sometimes depending on the amount and consistency of the was and your own comfort it may not be possible to remove all the wax in one your aural care practitioner will advise you to continue to use wax softener and return in a few days to have the remainder removed. There is cost if this is required.

Onward referral

On occasion it may be necessary to reject you for this procedure or refer onwards to another professional such as your GP or ENT specialist your aural care practitioner will discuss this with you the reasons and provide documentation if required.

Wax removal costs

The cost of wax removal is £50 for 1 ear or £70 for both ears. If there is no wax present there is a consultation fee of £30. Payment is made a appointment.

Name
Do you suffer from any condition that causes balance problems or vertigo attacks?
Have you had a vertigo attack within the last 30 days?
Have you suffered from any pain and or discharge in your ears within the last 30 days?
Do you have a perforated ear drum?
Have you had any fluid discharge from your ears within the last 30 days (excluding wax)?
Do you have persistent tinnitus (usually a ringing or buzzing noise in your head or ears)?
Which ear do you feel is blocked with wax?
Have you tried to remove the wax yourself using ear drops?
Have you had any previous operations on your ears?
Are you currently under an ENT Consultant or receiving any treatment regarding your ears?
Are you using anticoagulants, e.g. Warfarin?
Have you had ear wax removed from your ears previously?
When did you last have ear wax removed?
I have read all the information above and understand the risks involved in wax removal
I give my consent to allow the aural care practitioner to use the safest and most appropriate method of wax removal for me
I understand that the removal may take more than one visit and it maybe necessary to refer me to a medical professional if any complications arise
I sign to confirm I have read & understand the terms & conditions above & am willing to be bound by them. I accept & understand the terms & conditions.

Your Aural Care Practitioner has undertaken training in wax removal and will use best practice procedures to minimise any risk of harm. How performed with the utmost of care, there are small risks involved in wax removal. These include damage to the skin of the ear canal or eardrum procedure; infection of the ear canal or other ear structures following the procedure; temporary reduction in hearing; permanent reduction temporary dizziness and (rarely) possibly sickness or fainting; triggering of new tinnitus or temporary aggravation of existing tinnitus, tempo the throat, especially if already dry, tickly or sensitive.

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 patient remains relatively still during the procedure as sudden movement may significantly increase the risk of damage.

The CE marked suction unit is to remove fluids from the airway or respiratory support system and infectious materials from wounds and has 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 at Hearing and Balance Services LLP or any of its practitioners and employees, cannot not be held responsible for them.

Chester Hearing and Balance Services is governed by these terms and conditions.

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

Get in touch with Chester Hearing & Balance Services today for expert hearing solutions.

Call us today on 01244 680214 or on 07938 942420

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