Name: Ear Wax In Ear Wax Out
Telephone: 07411 264912

Consent Form

Prior to your consultation please complete the consent form.

Telephone: 07411 264912

Mobile ear wax removal service covering North Tyneside and Northumberland.

Ear wax removal via micro suction and water irrigation is considered safer than other methods, such as syringing. The ear wax removal will be carried out by a trained clinician. Complications of ear wax removal by 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 the ear wax requiring a return visit, for severally impacted wax, minor bleeding, discomfort, ringing in the ears (tinnitus), perforation of the ear drum and hearing loss.

To ensure the risk of complication is minimised, it is essential that accurate past medical history is supplied to our clinician. In addition, it is important 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.

By agreeing to the terms and conditions above, you accept that you have read and understood the possible complications that may occur and agree that Ear Wax In Ear Wax Out Ltd cannot be held responsible for these. I have read and understood these terms and conditions and am willing to be bound by them.

Name*

This field is mandatory

E-mail*

This field is mandatory

The e-mail address is invalid

Contact Number*

This field is mandatory

Address Including Postcode*

This field is mandatory

Describe your hearing problem.*

This field is mandatory

Which ears are causing you problems? Right/Left/Both Ears *

This field is mandatory

Have you suffered from any pain your ears over the last 30 days? Yes/No *

This field is mandatory

Have you tried to remove the ear wax yourself? Yes/No *

This field is mandatory

Do you have a perforated ear drum? Yes/No *

This field is mandatory

Are you currently under an ENT consultant or receiving treatment regarding your ears? Yes/No*

This field is mandatory

Do you suffer from any conditions that causes balance problems or vertigo attacks? If so please describe.*

This field is mandatory

Have you had Ear Wax removed from your ears previously? Yes/No*

This field is mandatory

Are you currently using any anti-coagulants? E.g. Warfarin, Clopidogrel, Apixiban, Rivaroxaban, Aspirin etc? Yes/No *

This field is mandatory

Are you aware of any reason why you should not proceed with micro-suction? Yes/No *

This field is mandatory

I have read and agreed to the terms and conditions above and understand that the personal information is held about me.*

This field is mandatory

Full Name and Date.*

This field is mandatory

I hereby agree that this data will be stored and processed for the purpose of establishing contact. I am aware that I can revoke my consent at any time.*

* Indicates required fields

There was an error submitting your message. Please try again.

Thank you! We will get back to you as soon as possible.