Patient Consent Form

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Patient Consent Form Submitted – Thank You

A patient consent form is to be completed prior to any appointment to ensure the patient is clinically suitable and to establish how best to provide treatment based on the patients individual medical history.

To safely remove any earwax or foreign bodies present within the ear canal, it is important that the clinical ear care practitioner is made fully aware of anything which may have an effect on the procedure.

Please answer the following questions regarding your hearing health by selecting the relevant boxes.

Do you suffer from any condition that may result in dizziness or balance problems ?(required)

Are you using any anti-platelet or anti-coagulant blood thinning medication ?(required)

Do you suffer from any condition that may cause or result in sudden movements ?(required)

Are you currently under an ENT consultant regarding your ear/s ?(required)

Have you had any surgical operations on your ears within the last 90 days ?(required)

Do you currently have grommets in situ or removed within the last 90 days ?(required)

Do you have persistent tinnitus or have an increased sensitivity to loud noises ?(required)

Have you suffered from any pain in your ears within the last 90 days ?(required)

Have you had an ear infection or any discharge from your ear/s within the last 90 days ?(required)

Have you suffered from a perforated eardrum within the last 90 days ?(required)

Have you had earwax removed previously ?(required)

History of any complications from previous earwax removal procedures ?(required)

Are you aware of any reasons as to why you cannot proceed with microsuction ?(required)

Does Ear Clear Healthcare have consent to contact your GP if required to do so ?(required)

The answers you have provided within this Clear Ear Healthcare patient consent form will be stored electronically along with other patient data and held as part of your case history. It will only be shared with other medical professionals, with the consent as the patient, where it helps with further patient assessment and/or treatment. It will never be used for marketing purposes. These records shall be kept for a minimum of 8 years as recommended by The British Society of Hearing Aid Audiologists (BSHAA).

Statement of Consent

I understand that personal information will be held about me and only shared with medical professionals where it may help with further patient assessment and/or treatment.

I have read and understood the Clear Ear Healthcare Terms of Service.

I have read and understood the Clear Ear Healthcare Patient Information Sheet.

I understand and acknowledge that there may be risks involved with earwax removal, however the risks have been explained to me by the Clinical Ear Care Practitioner.

I have informed the Clinical Ear Care Practitioner of all known medical conditions, medications and other factors that may affect my suitability for any or all forms of earwax removal.

I hereby give Clear Ear Healthcare informed consent to capture clinical images and video recordings only for the purpose of patient monitoring and/or treatment.

I hereby give the Clinical Ear Care Practitioner informed consent to remove wax from my ear/s using the procedure most appropriate for my personal circumstances.

I agree with the statement of consent and am willing to be bound by them(required)

‘Life is Worth Hearing’