Consent form for Ear Wax Removal

The purpose of earwax removal via micro-suction or the instruments is to safely remove any wax or foreign bodies present within the ear canal. To ensure this process is safely carried out it is important that the clinician is made aware of anything which may have a bearing on the procedure. Please answer these questions regarding your hearing health, ticking the relevant box:

  1. Have you suffered from any pain in your ears within the last 30 days?
    YesNo
  2. Do you have a perforated eardrum?
    YesNo
  3. Have you tried to remove wax yourself?
    YesNo
  4. Are you currently under an ENT Consultant or receiving any treatment regarding your ears?
    YesNo
  5. Are you using anticoagulants or blood thinning agents, e.g. Warfarin, Aspirin etc.?
    YesNo
  6. Do you suffer from Diabetes or blood clotting disorder?
    YesNo
  7. Are you aware of any reason as to why you should not proceed with micro suction?
    YesNo
  8. Have you had wax removed from your ears previously?
    YesNo
  9. If you have answered 'yes' to any of the above, please give the details here:

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 click this box to confirm (*required)