Microsuction & Irrigation Ear Wax Removal Consent Form Ear Wax Removal Consent FormTo ensure the safe removal of any wax or foreign objects from your ear canal, it is essential that the clinician is fully informed of any factors that may affect the procedure. Please answer the following questions about your hearing health by ticking and completing the relevant sections below:Do you suffer from any condition that causes balance problems or vertigo attacks? (If you begin to feel even the the slightest bit dizzy or faint during the procedure it is important that you let the clinician know at the very first sign.) Yes NoHave you had any fluid discharge from your ear/s within the last 30 days? Yes NoHave you suffered any pain in your ears within the last 30 days? Yes NoPain level Slight Significant ExcrutiatingAre you aware of, or suspect you may have or have had a perforated ear drum? Yes NoHave you tried to remove the wax yourself other than using ear drops? Yes NoHave you had any surgical operations on your ears, nose or throat? Yes NoWhich one? Left ear Right ear Nose ThroatHow long ago? (Years, Months)Are you currently under an ENT Consultant or receiving any treatment regarding your ears? Yes NoTreatment DetailsAre you using any antiplatelet or anticoagulant blood thinners? (E.g. Warfarin) Yes NoBlood Thinner DetailsDo you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)? Yes NoWhich ear/s? Left Right BothHave you had wax removed from your ears previously? Yes – microsuction Yes – other NoDo any of the following apply to you? (Optional – Tick if applicable) Impaired immune system- diabetes, cancer, HIV, HEP B, MRSA, etc. Radiotherapy on the head/neck. Recent metallic taste sensations Recent facial tingling or numbnessPatients with conditions like diabetes, cancer, HIV, Hepatitis B, or MRSA are asked about their immune status because: They may be more susceptible to infections during or after the procedure. Certain earwax removal methods might pose a higher risk for these individuals. Special precautions or alternative techniques may be necessary to minimise infection risks. This question is asked because: Radiation therapy can affect the ear’s structure and function, potentially altering earwax production and accumulation. It may cause changes in the ear canal’s skin, making it more sensitive or prone to injury during earwax removal. Patients who have undergone radiotherapy may be at higher risk for complications such as osteoradionecrosis of the external auditory canal Enquiring about metallic taste is important because: It could indicate recent ear surgery or damage to the chorda tympani nerve, which affects taste perception. A metallic taste might be a sign of an underlying condition affecting the ear or surrounding structures. Certain earwax removal methods might exacerbate this symptom if it’s related to a pre-existing ear condition. This question is asked because: Facial tingling or numbness could be a sign of nerve involvement or damage in the ear region. It might indicate a more complex ear condition that requires careful consideration during earwax removal. Certain removal techniques might be contraindicated if there’s suspected nerve involvement. Any details regarding the aboveAre you aware of any reason as to why you should not proceed with microsuction or irrigation? Yes No Please discuss this with your clinician before signing this form. Patient First NamePatient Last NamePatient signature: (or signature of parent if under 16, guardian or attorney if appropriate) Sign Here Date of signature: I have read and understood the terms of service and am willing to be bound by them.Submit
