Earwax Removal Consent Form – Visionary Eyecare

Microsuction & Irrigation Ear Wax Removal Consent Form

Ear Wax Removal Consent Form

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

Have you had any fluid discharge from your ear/s within the last 30 days?

Yes

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

Yes

Pain level

Slight

Significant

Excrutiating

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

Yes

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

Yes

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

Yes

Which one?

Left ear

Right ear

Nose

Throat

How long ago? (Years, Months)

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

Yes

Treatment Details

Are you using any antiplatelet or anticoagulant blood thinners? (E.g. Warfarin)

Yes

Blood Thinner Details

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

Yes

Which ear/s?

Left

Right

Both

Have you had wax removed from your ears previously?

Yes – microsuction

Yes – other

Do 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 numbness

Patients 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 above

Are you aware of any reason as to why you should not proceed with microsuction or irrigation?

Yes

Please discuss this with your clinician before signing this form.

Ear-Wax Removal: Fees, Payment and Attendance Policy

Please read this section in addition to the existing ear-wax removal consent form.

1. Treatment Fees

Visionary Eyecare UK Ltd charges the following fees for ear-wax removal:

One ear: £59 per visit
Both ears: £69 per visit

Where further visits are required, the applicable treatment fee will be charged for each subsequent visit in which treatment is provided.

2. Attendance Fee Policy

We understand that there may be circumstances in which our practitioner attends a scheduled appointment but cannot proceed with ear-wax removal.

A £30 attendance fee may apply when treatment cannot proceed for reasons covered by this policy.

The attendance fee may apply in circumstances such as:

The resident is unavailable at the agreed appointment time.
The resident is unable or unwilling to proceed with the procedure at the time of the visit.
Treatment cannot proceed for another reason covered by the attendance policy that was explained before the appointment was confirmed.

Clinical and Safety Considerations

The safety and wellbeing of the resident will always take priority.

If our practitioner determines that treatment should not proceed for clinical or safety reasons, such as a suspected ear infection or another contraindication, treatment will not be carried out.

No attendance fee will be charged where our practitioner determines that treatment is clinically inappropriate or unsafe.

Where treatment cannot proceed for another reason, the attendance fee will be considered in accordance with this policy and the circumstances of the visit.

3. Subsequent Visits

If further treatment is required, a subsequent appointment may be arranged.

Where treatment is provided at a subsequent visit, the applicable treatment fee of £59 for one ear or £69 for both ears will apply.

Where treatment cannot proceed again, the attendance-fee policy outlined above will apply, where appropriate.

4. Agreement to Fees and Payment

By signing this agreement, I confirm that:

I have read and understood the treatment fees and attendance policy.
I understand that the fee will depend on the treatment provided and the circumstances of the visit.
I understand that a £30 attendance fee may apply where treatment cannot proceed for reasons covered by the attendance policy.
I understand that no attendance fee will be charged where the practitioner determines that treatment is clinically inappropriate or unsafe.
I have had the opportunity to ask questions about the fees and charges.
I agree to pay the applicable charges in accordance with this agreement.

Next of Kin Details

Next of Kin Name

Next of Kin Email Address

Next of Kin Phone Number

Patient Details

Patient First Name

Patient Last Name

Payer Details

Name of Person Responsible for Payment

Care Home Name

Relationship to Resident

Declaration

I confirm that the information provided above is accurate and that I understand and agree to the fees and attendance policy outlined in this document.

I understand that this agreement relates to payment and is separate from consent to clinical treatment.

I have read and understood the terms of service and am willing to be bound by them.

Patient signature: (or signature of parent if under 16, guardian or attorney if appropriate)

Sign Here

Date of signature: