Micro Suction Ear Wax Removal Consent Form

To safely remove any wax or foreign bodies present within the ear canal, it is important that the clinician is made fully aware of anything which may have a bearing on the procedure. Please answer the following questions regarding your hearing health by ticking and completing the relevant boxes:

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


Do you know if you have had an ear infection within the last 30 days?


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


Are you aware of, or suspect you may have a perforated ear drum?


Have you tried to remove the wax yourself other than using ear drops?


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


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


Are you using any antiplatelet or anticoagulant blood thinners (e.g. Warfarin, Aspirin etc.)?


Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?


Have you had wax removed from your ears previously?

Yes - micro suctionYes - otherNo

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



Terms and Conditions:

  1. Earwax removal at this clinic is governed by these terms and conditions: Your Ear Care Professional has undertaken training in wax removal and will use best-practice procedures to minimise any risk of harm. However, even when performed with the utmost care, there are risks involved in wax removal. Wax removal via microsuction is considered safer than other methods such as syringing.
  2. Complications of ear wax removal with microsuction or instruments 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 eardrum and hearing loss.
  3. To ensure the risk of complication is minimised, it is essential that accurate past medical history is supplied to us. Therefore, please answer all the questions in the above questionnaire. In addition, it is important that the patient remains relatively still during the procedure as a sudden movement may significantly increase the risk of eardrum perforation, permanent hearing loss and/or bleeding.
  4. 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 microsuction.

    Your Consent: I accept these terms & conditions and understand the possible complications that may occur during the appointment. I agree that my Ear and Hearing Care Professional and/or Audiology Planet cannot be held responsible for any complications and that the wax removal may take more than one attempt.

    Please sign and submit your response below. By submitting your response, you are also consenting to the conditions laid out in PRIVACY CONSENT STATEMENT for attending the appointment available here and WEBSITE TERMS AND CONDITIONS available here Furthermore, the answers you provide will be stored along with other patient data and held as part of your case history. It will only be shared with other medical professionals where it helps with further assessment or treatment.

    Date of signature:

By |2019-03-11T22:46:27+00:00March 11th, 2019|Blog|0 Comments

About the Author:

Jay Jindal is a highly qualified independent audiologist, specialising in hearing care for both children and adults, auditory processing disorders, balance & dizziness and tinnitus management. His clinics are in Bromley, Orpington, Sevenoaks, Tunbridge Wells and Maidstone. Jay speaks on various audiology related topics at national and international events. He also organises world class paediatric and adult audiology events with speakers from all over the world via www.audiologyplanet.com Jay is associated with several national bodies related to audiology, which have a great influence on how the hearing healthcare services are provided in United Kingdom. He is the Professional Development Consultant for British Society of Hearing Aid Audiologists (BSHAA) which is the professional body of hearing aid audiologists in UK and has around 1600+ members. He is also a member of the prestigious national level Document Guidance Group of British Society of Audiologists (BSA). This group produces guidance and recommended procedures that are used by audiologists in the NHS and independent clinics throughout the UK. He is also a member of regulatory body’s (Health and Care Professional Council) fitness-to-practice panel formulated to investigate the malpractices of hearing aid audiologists

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