{"id":2108,"date":"2025-04-10T20:23:02","date_gmt":"2025-04-10T20:23:02","guid":{"rendered":"https:\/\/v-eyecare.com\/?page_id=2108"},"modified":"2025-04-10T21:04:17","modified_gmt":"2025-04-10T21:04:17","slug":"earwax-removal-consent-form","status":"publish","type":"page","link":"https:\/\/v-eyecare.com\/index.php\/earwax-removal\/earwax-removal-consent-form\/","title":{"rendered":"Earwax Removal Consent Form"},"content":{"rendered":"<style>.kb-row-layout-id2108_f81f31-dc > .kt-row-column-wrap{align-content:end;}:where(.kb-row-layout-id2108_f81f31-dc > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:end;}.kb-row-layout-id2108_f81f31-dc > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:var( --global-content-width, 1170px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:0px;padding-bottom:0px;min-height:30vh;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id2108_f81f31-dc > .kt-row-layout-overlay{opacity:0.30;}.kb-row-layout-id2108_f81f31-dc .kt-row-layout-top-sep{height:73px;}.kb-row-layout-id2108_f81f31-dc .kt-row-layout-top-sep svg{width:100%;}.kb-row-layout-id2108_f81f31-dc .kt-row-layout-top-sep svg{fill:#ffffff!important;}@media all and (max-width: 1024px){.kb-row-layout-id2108_f81f31-dc > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id2108_f81f31-dc > .kt-row-column-wrap{min-height:24vh;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id2108_f81f31-dc > .kt-row-layout-overlay{opacity:0.60;background:var(--global-palette9, #ffffff);}.kb-row-layout-id2108_f81f31-dc .kt-row-layout-top-sep{height:32px;}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id2108_f81f31-dc alignfull wp-block-kadence-rowlayout\"><div class=\"kt-row-layout-overlay kt-row-overlay-normal\"><\/div><div class=\"kt-row-layout-top-sep kt-row-sep-type-crvli\"><svg viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\"><path d=\"M1000,0c0,0 -420.987,98 -650,98c-229.013,0 -350,-98 -350,-98l0,100l1000,0l0,-100Z\" \/><\/svg><\/div><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-bottom kt-inner-column-height-full kb-theme-content-width\">\n<style>.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{display:flex;}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{padding-bottom:var(--global-kb-spacing-md, 2rem);padding-left:0px;}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{min-height:0vh;}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-end;}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col > .aligncenter{width:100%;}.kt-row-column-wrap > .kadence-column2108_5f2b1a-52{align-self:flex-end;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-end;}.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column2108_5f2b1a-52{position:relative;}@media all and (max-width: 1024px){.kt-row-column-wrap > .kadence-column2108_5f2b1a-52{align-self:flex-end;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52{align-self:auto;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-end;}}@media all and (max-width: 1024px){.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-end;}}@media all and (max-width: 767px){.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{padding-bottom:var(--global-kb-spacing-sm, 1.5rem);padding-left:0px;flex-direction:column;justify-content:flex-end;}.kt-row-column-wrap > .kadence-column2108_5f2b1a-52{align-self:flex-end;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-end;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column2108_5f2b1a-52 kb-section-dir-vertical\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30, .wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30[data-kb-block=\"kb-adv-heading2108_050a4a-30\"]{max-width:40vw;padding-bottom:var(--global-kb-spacing-sm, 1.5rem);padding-left:var(--global-kb-spacing-xs, 1rem);text-align:left;font-size:var(--global-kb-font-size-lg, 2rem);line-height:1.2;font-weight:700;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30[data-kb-block=\"kb-adv-heading2108_050a4a-30\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30[data-kb-block=\"kb-adv-heading2108_050a4a-30\"] img.kb-inline-image{width:150px;vertical-align:baseline;}@media all and (max-width: 767px){.wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30, .wp-block-kadence-advancedheading.kt-adv-heading2108_050a4a-30[data-kb-block=\"kb-adv-heading2108_050a4a-30\"]{max-width:100vw;font-size:var(--global-kb-font-size-xl, 3rem);text-align:left!important;}}<\/style>\n<h2 class=\"kt-adv-heading2108_050a4a-30 wp-block-kadence-advancedheading has-theme-palette-3-color has-text-color\" data-kb-block=\"kb-adv-heading2108_050a4a-30\">Microsuction &amp; Irrigation Ear Wax Removal Consent Form<\/h2>\n<\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id2108_22839f-d5 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id2108_22839f-d5 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id2108_22839f-d5 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:1140px;margin-left:auto;margin-right:auto;padding-bottom:var(--global-kb-spacing-xl, 4rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id2108_22839f-d5 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id2108_22839f-d5 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id2108_22839f-d5 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id2108_22839f-d5 alignfull has-theme-palette9-background-color kt-row-has-bg wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column2108_14a8f6-57 > .kt-inside-inner-col{display:flex;}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col{flex-direction:column;align-items:center;}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col > .kb-image-is-ratio-size{align-self:stretch;}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col > .wp-block-kadence-advancedgallery{align-self:stretch;}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column2108_14a8f6-57 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column2108_14a8f6-57{position:relative;}@media all and (max-width: 1024px){.kadence-column2108_14a8f6-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;align-items:center;}}@media all and (max-width: 767px){.kadence-column2108_14a8f6-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;align-items:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column2108_14a8f6-57 inner-column-1\"><div class=\"kt-inside-inner-col\"><div class='fluentform ff-default fluentform_wrapper_3  ff_guten_block ff_guten_block-3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Ear Wax Removal Consent Form<\/legend><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"62\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='2108' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"5e7d6b6acc\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2108\" \/><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >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.)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='balance_problems_90fad0c8eb9c53010e5dba7eb15b91cd'><input  type=\"radio\" name=\"balance_problems\" data-name=\"balance_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='balance_problems_90fad0c8eb9c53010e5dba7eb15b91cd' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='balance_problems_7f803e7ef3304fbd1880baec4771c1dd'><input  type=\"radio\" name=\"balance_problems\" data-name=\"balance_problems\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='balance_problems_7f803e7ef3304fbd1880baec4771c1dd' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Have you had any fluid discharge from your ear\/s within the last 30 days?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='ear_discharge_ee9b65dedb0c454e0710401657d09c94'><input  type=\"radio\" name=\"ear_discharge\" data-name=\"ear_discharge\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='ear_discharge_ee9b65dedb0c454e0710401657d09c94' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='ear_discharge_2b283d61be4a1e77e30779616d60f6d8'><input  type=\"radio\" name=\"ear_discharge\" data-name=\"ear_discharge\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='ear_discharge_2b283d61be4a1e77e30779616d60f6d8' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Have you suffered any pain in your ears within the last 30 days?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='ear_pain_e01c09ed84c5b5a44077f31b035c96e3'><input  type=\"radio\" name=\"ear_pain\" data-name=\"ear_pain\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='ear_pain_e01c09ed84c5b5a44077f31b035c96e3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='ear_pain_25ae40474d5065e4abaea55eaebf30ff'><input  type=\"radio\" name=\"ear_pain\" data-name=\"ear_pain\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='ear_pain_25ae40474d5065e4abaea55eaebf30ff' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  >Pain level<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='ear_pain_1_f2094c6485f298721c19189d423865bf'><input  type=\"radio\" name=\"ear_pain_1\" data-name=\"ear_pain_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Slight\"  id='ear_pain_1_f2094c6485f298721c19189d423865bf' aria-label='Slight' aria-invalid='false' aria-required=false> <span>Slight<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='ear_pain_1_7f37ccdac7e10ba080f0eab4325bf131'><input  type=\"radio\" name=\"ear_pain_1\" data-name=\"ear_pain_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Significant\"  id='ear_pain_1_7f37ccdac7e10ba080f0eab4325bf131' aria-label='Significant' aria-invalid='false' aria-required=false> <span>Significant<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='ear_pain_1_556d233770c5ae24bcca5e33bd0b5812'><input  type=\"radio\" name=\"ear_pain_1\" data-name=\"ear_pain_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Excrutiating\"  id='ear_pain_1_556d233770c5ae24bcca5e33bd0b5812' aria-label='Excrutiating' aria-invalid='false' aria-required=false> <span>Excrutiating<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Are you aware of, or suspect you may have or have had a perforated ear drum?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_53cc7fac44f3bad465fd524382c2c7c0'><input  type=\"radio\" name=\"perforated_eardrum\" data-name=\"perforated_eardrum\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_53cc7fac44f3bad465fd524382c2c7c0' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_5fc65993c6803e68bda1b5f2d1ac3b10'><input  type=\"radio\" name=\"perforated_eardrum\" data-name=\"perforated_eardrum\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_5fc65993c6803e68bda1b5f2d1ac3b10' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Have you tried to remove the wax yourself other than using ear drops?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_1_02da086ab6e95dbd14b63862f20cefb0'><input  type=\"radio\" name=\"perforated_eardrum_1\" data-name=\"perforated_eardrum_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_1_02da086ab6e95dbd14b63862f20cefb0' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_1_1c8bb710d52dfb43f3b9f2b0b6a65834'><input  type=\"radio\" name=\"perforated_eardrum_1\" data-name=\"perforated_eardrum_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_1_1c8bb710d52dfb43f3b9f2b0b6a65834' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Have you had any surgical operations on your ears, nose or throat?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_2_6183197a0b3dd6bc93b577f5849f107f'><input  type=\"radio\" name=\"perforated_eardrum_2\" data-name=\"perforated_eardrum_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_2_6183197a0b3dd6bc93b577f5849f107f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_2_85382b773ce44ad3eea61c47aa2f6dbf'><input  type=\"radio\" name=\"perforated_eardrum_2\" data-name=\"perforated_eardrum_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_2_85382b773ce44ad3eea61c47aa2f6dbf' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Which one?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6fb46cf4ac8969c336e4ee8c2fbbe72e'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Left ear\"  id='checkbox_6fb46cf4ac8969c336e4ee8c2fbbe72e' aria-label='Left ear' aria-invalid='false' aria-required=true> <span>Left ear<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_d35ddbb45d56b14b7d4962cecf6036cf'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Right ear\"  id='checkbox_d35ddbb45d56b14b7d4962cecf6036cf' aria-label='Right ear' aria-invalid='false' aria-required=true> <span>Right ear<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_ae91ac3726bf1c62fcad1e4075da4c87'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Nose\"  id='checkbox_ae91ac3726bf1c62fcad1e4075da4c87' aria-label='Nose' aria-invalid='false' aria-required=true> <span>Nose<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3c6ef2475b9355dcf96fe18bb2e9c0d4'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Throat\"  id='checkbox_3c6ef2475b9355dcf96fe18bb2e9c0d4' aria-label='Throat' aria-invalid='false' aria-required=true> <span>Throat<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text' id='label_ff_3_input_text'>How long ago? (Years, Months)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Are you currently under an ENT Consultant or receiving any treatment regarding your ears?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_3_7e96e4eb9618ef3c5992dcfdc85d0da9'><input  type=\"radio\" name=\"perforated_eardrum_3\" data-name=\"perforated_eardrum_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_3_7e96e4eb9618ef3c5992dcfdc85d0da9' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_3_ec833889fe561f6994167f71ec617d6d'><input  type=\"radio\" name=\"perforated_eardrum_3\" data-name=\"perforated_eardrum_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_3_ec833889fe561f6994167f71ec617d6d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_1' id='label_ff_3_input_text_1'>Treatment Details<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Are you using any antiplatelet or anticoagulant blood thinners? (E.g. Warfarin)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_4_17b219d245538fa37f8332bb6cf3168a'><input  type=\"radio\" name=\"perforated_eardrum_4\" data-name=\"perforated_eardrum_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_4_17b219d245538fa37f8332bb6cf3168a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_4_2624ea4d50b7b36edc8ac776318cf028'><input  type=\"radio\" name=\"perforated_eardrum_4\" data-name=\"perforated_eardrum_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_4_2624ea4d50b7b36edc8ac776318cf028' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_2' id='label_ff_3_input_text_2'>Blood Thinner Details<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_5_dea198b011695da1c64a71b20ed48d98'><input  type=\"radio\" name=\"perforated_eardrum_5\" data-name=\"perforated_eardrum_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_5_dea198b011695da1c64a71b20ed48d98' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_5_888e228a47bb3abd4a1e3425b2563475'><input  type=\"radio\" name=\"perforated_eardrum_5\" data-name=\"perforated_eardrum_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_5_888e228a47bb3abd4a1e3425b2563475' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label  >Which ear\/s?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_9_1f609b63bde7d3fd422e5961da5b2817'><input  type=\"radio\" name=\"perforated_eardrum_9\" data-name=\"perforated_eardrum_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Left\"  id='perforated_eardrum_9_1f609b63bde7d3fd422e5961da5b2817' aria-label='Left' aria-invalid='false' aria-required=false> <span>Left<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_9_e13c78c52da81e052b6f22b69d547eba'><input  type=\"radio\" name=\"perforated_eardrum_9\" data-name=\"perforated_eardrum_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Right\"  id='perforated_eardrum_9_e13c78c52da81e052b6f22b69d547eba' aria-label='Right' aria-invalid='false' aria-required=false> <span>Right<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_9_c2c31b2127cb31005b07e1151d6054ee'><input  type=\"radio\" name=\"perforated_eardrum_9\" data-name=\"perforated_eardrum_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"Both\"  id='perforated_eardrum_9_c2c31b2127cb31005b07e1151d6054ee' aria-label='Both' aria-invalid='false' aria-required=false> <span>Both<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Have you had wax removed from your ears previously?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_6_7db2f218f85268a0880c3394b997aa1f'><input  type=\"radio\" name=\"perforated_eardrum_6\" data-name=\"perforated_eardrum_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Yes - microsuction\"  id='perforated_eardrum_6_7db2f218f85268a0880c3394b997aa1f' aria-label='Yes - microsuction' aria-invalid='false' aria-required=true> <span>Yes &#8211; microsuction<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_6_e1d0b8088f5157a86ba86c606c62e798'><input  type=\"radio\" name=\"perforated_eardrum_6\" data-name=\"perforated_eardrum_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\" Yes - other\"  id='perforated_eardrum_6_e1d0b8088f5157a86ba86c606c62e798' aria-label='Yes - other' aria-invalid='false' aria-required=true> <span> Yes &#8211; other<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_6_29ade095a22b5461347582d2e4da61fa'><input  type=\"radio\" name=\"perforated_eardrum_6\" data-name=\"perforated_eardrum_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"No\"  id='perforated_eardrum_6_29ade095a22b5461347582d2e4da61fa' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label  >Do any of the following apply to you? (Optional &#8211; Tick if applicable)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_5cce2bd16f09a4c1bcc1d718251c1983'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Impaired immune system- diabetes, cancer, HIV, HEP B, MRSA, etc.\"  id='checkbox_2_5cce2bd16f09a4c1bcc1d718251c1983' aria-label='Impaired immune system- diabetes, cancer, HIV, HEP B, MRSA, etc.' aria-invalid='false' aria-required=false> <span>Impaired immune system- diabetes, cancer, HIV, HEP B, MRSA, etc.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_1c2e52ef357e40659cfa1249a53d12ef'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Radiotherapy on the head\/neck.\"  id='checkbox_2_1c2e52ef357e40659cfa1249a53d12ef' aria-label='Radiotherapy on the head\/neck.' aria-invalid='false' aria-required=false> <span>Radiotherapy on the head\/neck.<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_00c2b8e031700c12cd8196ebb1f4352a'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Recent metallic taste sensations\"  id='checkbox_2_00c2b8e031700c12cd8196ebb1f4352a' aria-label='Recent metallic taste sensations' aria-invalid='false' aria-required=false> <span>Recent metallic taste sensations<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_eb6dee6059d23da570f0b407b9f3059b'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\" Recent facial tingling or numbness\"  id='checkbox_2_eb6dee6059d23da570f0b407b9f3059b' aria-label='Recent facial tingling or numbness' aria-invalid='false' aria-required=false> <span> Recent facial tingling or numbness<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_1\" ><p>Patients with conditions like diabetes, cancer, HIV, Hepatitis B, or MRSA are asked about their immune status because:<\/p>\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">They may be more susceptible to infections during or after the procedure.<\/li>\n<li class=\"RTE__listItem\">Certain earwax removal methods might pose a higher risk for these individuals.<\/li>\n<li class=\"RTE__listItem\">Special precautions or alternative techniques may be necessary to minimise infection risks.<\/li>\n<\/ul><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_2\" ><p dir=\"ltr\">This question is asked because:<\/p>\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">Radiation therapy can affect the ear&#8217;s structure and function, potentially altering earwax production and accumulation.<\/li>\n<li class=\"RTE__listItem\">It may cause changes in the ear canal&#8217;s skin, making it more sensitive or prone to injury during earwax removal.<\/li>\n<li class=\"RTE__listItem\">Patients who have undergone radiotherapy may be at higher risk for complications such as osteoradionecrosis of the external auditory canal<\/li>\n<\/ul><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_3\" ><p dir=\"ltr\">Enquiring about metallic taste is important because:<\/p>\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">It could indicate recent ear surgery or damage to the chorda tympani nerve, which affects taste perception.<\/li>\n<li class=\"RTE__listItem\">A metallic taste might be a sign of an underlying condition affecting the ear or surrounding structures.<\/li>\n<li class=\"RTE__listItem\">Certain earwax removal methods might exacerbate this symptom if it&#8217;s related to a pre-existing ear condition.<\/li>\n<\/ul><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_4\" ><p dir=\"ltr\">This question is asked because:<\/p>\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">Facial tingling or numbness could be a sign of nerve involvement or damage in the ear region.<\/li>\n<li class=\"RTE__listItem\">It might indicate a more complex ear condition that requires careful consideration during earwax removal.<\/li>\n<li class=\"RTE__listItem\">Certain removal techniques might be contraindicated if there&#8217;s suspected nerve involvement.<\/li>\n<\/ul><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_medical_conditions' id='label_ff_3_medical_conditions'>Any details regarding the above<\/label><\/div><div class='ff-el-input--content'><textarea aria-required=\"false\" aria-labelledby=\"label_ff_3_medical_conditions\" name=\"medical_conditions\" id=\"ff_3_medical_conditions\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"medical_conditions\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Are you aware of any reason as to why you should not proceed with microsuction or irrigation?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='perforated_eardrum_8_dab3232ff53ef0f03b7b1c8fc2204a84'><input  type=\"radio\" name=\"perforated_eardrum_8\" data-name=\"perforated_eardrum_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='perforated_eardrum_8_dab3232ff53ef0f03b7b1c8fc2204a84' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for='perforated_eardrum_8_58724af1b443d192a1b07c76f5d82457'><input  type=\"radio\" name=\"perforated_eardrum_8\" data-name=\"perforated_eardrum_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" value=\"no\"  id='perforated_eardrum_8_58724af1b443d192a1b07c76f5d82457' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_5\" ><div data-role=\"container\" data-type=\"virtual-form-table-row\" data-hash=\"00000039\" data-type-id=\"0\" data-colspan=\"20\" data-num-children=\"1\">\n<div data-role=\"control\" data-type=\"heading\" data-hash=\"0000003a\" data-type-id=\"7\" data-colspan=\"20\" data-field-name=\"If yes to shouldn't proceed\" data-id=\"50557400\" data-is-active=\"1\">\n<p id=\"heading-0000003a-acc\" class=\"text-left\" aria-labelledby=\"heading-0000003a-acc\" data-i18n-text=\"control_label_html_50557400\">Please discuss this with your clinician before signing this form.<\/p>\n<\/div>\n<\/div>\n<div data-role=\"container\" data-type=\"virtual-form-table-row\" data-hash=\"0000003b\" data-type-id=\"0\" data-colspan=\"20\" data-num-children=\"1\">\n<p data-role=\"control\" data-type=\"name\" data-hash=\"0000003c\" data-type-id=\"12\" data-colspan=\"20\" data-label-is-bold=\"1\" aria-labelledby=\"name-0000003c-acc\" aria-describedby=\"name-0000003c-instr-acc\" data-is-required=\"1\" data-renderer-type=\"tln\" data-id=\"50556328\">\u00a0<\/p>\n<\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_6\" ><h3 style=\"text-align: center\">Ear-Wax Removal: Fees, Payment and Attendance Policy<\/h3><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_7\" >\n<div style=\"font-size: 13px;color: #6b7280;line-height: 1.7\">\n\n<p style=\"margin-bottom: 24px\">Please read this section in addition to the existing ear-wax removal consent form.<\/p>\n\n<h5 style=\"font-size: 14px;color: #6b7280;margin-top: 28px;margin-bottom: 10px\">1. Treatment Fees<\/h5>\n\n<p>Visionary Eyecare UK Ltd charges the following fees for ear-wax removal:<\/p>\n\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\"><strong>One ear: \u00a359 per visit<\/strong><\/li>\n<li class=\"RTE__listItem\"><strong>Both ears: \u00a369 per visit<\/strong><\/li>\n<\/ul>\n\n<p>Where further visits are required, the applicable treatment fee will be charged for each subsequent visit in which treatment is provided.<\/p>\n\n<h5 style=\"font-size: 14px;color: #6b7280;margin-top: 32px;margin-bottom: 10px\">2. Attendance Fee Policy<\/h5>\n\n<p>We understand that there may be circumstances in which our practitioner attends a scheduled appointment but cannot proceed with ear-wax removal.<\/p>\n\n<p>A <strong>\u00a330 attendance fee may apply<\/strong> when treatment cannot proceed for reasons covered by this policy.<\/p>\n\n<p>The attendance fee may apply in circumstances such as:<\/p>\n\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">The resident is unavailable at the agreed appointment time.<\/li>\n<li class=\"RTE__listItem\">The resident is unable or unwilling to proceed with the procedure at the time of the visit.<\/li>\n<li class=\"RTE__listItem\">Treatment cannot proceed for another reason covered by the attendance policy that was explained before the appointment was confirmed.<\/li>\n<\/ul>\n\n<h5 style=\"font-size: 14px;color: #6b7280;margin-top: 24px;margin-bottom: 10px\">Clinical and Safety Considerations<\/h5>\n\n<p>The safety and wellbeing of the resident will always take priority.<\/p>\n\n<p>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.<\/p>\n\n<p><strong>No attendance fee will be charged where our practitioner determines that treatment is clinically inappropriate or unsafe.<\/strong><\/p>\n\n<p>Where treatment cannot proceed for another reason, the attendance fee will be considered in accordance with this policy and the circumstances of the visit.<\/p>\n\n<h5 style=\"font-size: 14px;color: #6b7280;margin-top: 32px;margin-bottom: 10px\">3. Subsequent Visits<\/h5>\n\n<p>If further treatment is required, a subsequent appointment may be arranged.<\/p>\n\n<p>Where treatment is provided at a subsequent visit, the applicable treatment fee of \u00a359 for one ear or \u00a369 for both ears will apply.<\/p>\n\n<p>Where treatment cannot proceed again, the attendance-fee policy outlined above will apply, where appropriate.<\/p>\n\n<h5 style=\"font-size: 14px;color: #6b7280;margin-top: 32px;margin-bottom: 10px\">4. Agreement to Fees and Payment<\/h5>\n\n<p>By signing this agreement, I confirm that:<\/p>\n\n<ul class=\"RTE__ul\">\n<li class=\"RTE__listItem\">I have read and understood the treatment fees and attendance policy.<\/li>\n<li class=\"RTE__listItem\">I understand that the fee will depend on the treatment provided and the circumstances of the visit.<\/li>\n<li class=\"RTE__listItem\">I understand that a \u00a330 attendance fee may apply where treatment cannot proceed for reasons covered by the attendance policy.<\/li>\n<li class=\"RTE__listItem\">I understand that no attendance fee will be charged where the practitioner determines that treatment is clinically inappropriate or unsafe.<\/li>\n<li class=\"RTE__listItem\">I have had the opportunity to ask questions about the fees and charges.<\/li>\n<li class=\"RTE__listItem\">I agree to pay the applicable charges in accordance with this agreement.<\/li>\n<\/ul>\n\n<\/div>\n<\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_8\" ><h3 style=\"text-align: center\">Next of Kin Details<\/h3><\/div><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_1_first_name_' id='label_ff_3_names_1_first_name_'>Next of Kin Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_3_names_1_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter the Next of Kin&#039;s Full Name\" autocomplete=\"given-name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' id='label_ff_3_email'>Next of Kin Email Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" autocomplete=\"email\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric_field' id='label_ff_3_numeric_field'>Next of Kin Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_3_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_9\" ><h3 style=\"text-align: center\">Patient Details<\/h3><\/div><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' id='label_ff_3_names_first_name_'>Patient First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" autocomplete=\"given-name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' id='label_ff_3_names_last_name_'>Patient Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" autocomplete=\"family-name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_10\" ><h3 style=\"text-align: center\">Payer Details<\/h3><\/div><div data-type=\"name-element\" data-name=\"names_5\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_5_first_name_' id='label_ff_3_names_5_first_name_'>Name of Person Responsible for Payment<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_5[first_name]\" id=\"ff_3_names_5_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Full Name\" autocomplete=\"given-name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_5_last_name_' id='label_ff_3_names_5_last_name_'>Care Home Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_5[last_name]\" id=\"ff_3_names_5_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Care Home Name\" autocomplete=\"family-name\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_4' id='label_ff_3_input_text_4'>Relationship to Resident<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_11\" ><h3 style=\"text-align: center\">Declaration<\/h3><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='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.' class='ff-el-form-check-label ff_tc_label' for='consent_agreement_3_68bc6ab24a6bb02afcb33842fd7cac49'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"consent_agreement_3\" class=\"ff-el-form-check-input\" data-name=\"consent_agreement_3\" id=\"consent_agreement_3_68bc6ab24a6bb02afcb33842fd7cac49\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><p>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.<\/p><\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='I understand that this agreement relates to payment and is separate from consent to clinical treatment.' class='ff-el-form-check-label ff_tc_label' for='consent_agreement_2_5f79b1ded643834934808b5797005b91'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"consent_agreement_2\" class=\"ff-el-form-check-input\" data-name=\"consent_agreement_2\" id=\"consent_agreement_2_5f79b1ded643834934808b5797005b91\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><p>I understand that this agreement relates to payment and is separate from consent to clinical treatment.<\/p><\/div><\/label><\/div><\/div><div class='ff-el-group    ff-el-input--content'><div class='ff-el-form-check ff-el-tc'><label aria-label='Terms and Conditions: I have read and understood the\u00a0terms of service and am willing to be bound by them. Contains 1 link. Use tab navigation to review.' class='ff-el-form-check-label ff_tc_label' for='consent_agreement_1_25cae21ede56b88fc7b5e9e2bd464bcf'><span class='ff_tc_checkbox'><input type=\"checkbox\" name=\"consent_agreement_1\" class=\"ff-el-form-check-input\" data-name=\"consent_agreement_1\" id=\"consent_agreement_1_25cae21ede56b88fc7b5e9e2bd464bcf\"  value='on' aria-invalid='false' aria-required=true><\/span> <div class='ff_t_c'><p>I have read and understood the\u00a0<a href=\"https:\/\/v-eyecare.com\/index.php\/wax-removal-terms-of-service\/\" target=\"_blank\" rel=\"noopener\">terms of service<\/a> and am willing to be bound by them.<\/p><\/div><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >Patient signature: (or signature of parent if under 16, guardian or attorney if appropriate)<\/label><\/div><div class='ff-el-input--content'><input type='text' name='signature' class='force-hide'>\n\n<div class=\"fluentform-signature-pad-wrapper\">\n    <canvas id='signature_3' \n            class='fluentform-signature-pad' \n            data-form-id='3'\n            data-pen-color='#333'\n            data-pen-size='2'\n            style='\n                background-color: #ffffff;\n                border: 2px dashed #FFEB3B;\n                width: fit-content;\n            '\n            height=\"200\"\n    ><\/canvas>\n\n    <div class=\"ff-el-signature__actions\">\n        <div class='fluentform-signature-pad-actions'>\n            <button type='button' class='fluentform-signature-button fluentform-signature-clear'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 561 561\" xml:space=\"preserve\"><g><g id=\"loop\"><path d=\"M280.5,76.5V0l-102,102l102,102v-76.5c84.15,0,153,68.85,153,153c0,25.5-7.65,51-17.85,71.4l38.25,38.25C471.75,357,484.5,321.3,484.5,280.5C484.5,168.3,392.7,76.5,280.5,76.5z M280.5,433.5c-84.15,0-153-68.85-153-153c0-25.5,7.65-51,17.85-71.4l-38.25-38.25C89.25,204,76.5,239.7,76.5,280.5c0,112.2,91.8,204,204,204V561l102-102l-102-102V433.5z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n            \n            <button type='button' class='fluentform-signature-button fluentform-signature-undo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 497.25 497.25\" xml:space=\"preserve\"><g><g id=\"undo\"><path d=\"M248.625,89.25V0l-127.5,127.5l127.5,127.5V140.25c84.15,0,153,68.85,153,153c0,84.15-68.85,153-153,153c-84.15,0-153-68.85-153-153h-51c0,112.2,91.8,204,204,204s204-91.8,204-204S360.825,89.25,248.625,89.25z\"\/><\/g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n\n            <button type='button' class='fluentform-signature-button fluentform-signature-redo'>\n                <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" x=\"0px\" y=\"0px\" viewBox=\"0 0 485.212 485.212\" xml:space=\"preserve\"><g><path d=\"M242.607,424.559c-75.252,0-136.468-61.209-136.468-136.465c0-75.252,61.216-136.466,136.468-136.466v90.978l151.629-121.302L242.607,0v90.978c-108.687,0-197.117,88.432-197.117,197.117c0,108.691,88.43,197.118,197.117,197.118c108.687,0,197.114-88.427,197.114-197.118h-60.645C379.077,363.35,317.859,424.559,242.607,424.559z\"\/><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><g><\/g><\/svg>\n            <\/button>\n        <\/div>\n\n        <div class='ff-el-signature__actions-hint fluentform-signature-hint'>Sign Here<\/div>\n    <\/div>\n<\/div>\n<\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime' id='label_ff_3_datetime'>Date of signature:<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of signature: Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-form-inline-style' hidden><style>form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit { background-color:#1a7efb;border-color:#1a7efb;color:#ffffff;min-width:100%; }form.fluent_form_3 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#1a7efb;color:#1a7efb;min-width:100%; } <\/style><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-3_12\" data-name=\"custom_submit_button-3_12\"  aria-label=\"Submit\">Submit<\/button><\/div><\/fieldset><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_1 ff-form-loading_errors ff_form_instance_3_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_3_1 = {\"id\":\"3\",\"ajaxUrl\":\"https:\\\/\\\/v-eyecare.com\\\/wp-admin\\\/admin-ajax.php\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_3_1\",\"form_id_selector\":\"fluentform_3\",\"rules\":{\"balance_problems\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"ear_discharge\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"ear_pain\":{\"required\":{\"value\":true,\"message\":\"This 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