{"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,.kadence-column2108_5f2b1a-52 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.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;}@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,.kadence-column2108_14a8f6-57 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.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=\"124\"\/><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=\"55abc9bc0f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/2108\" \/><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><p class=\"\" data-start=\"79\" data-end=\"374\"><strong>To 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:<\/strong><\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-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.)\">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'><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_5687049e0eeea728ffd408b62ddf5e65' 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'><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_1835bc206c33d8d5afd2ecc3a1db7ee7' 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   aria-label=\"Have you had any fluid discharge from your ear\/s within the last 30 days?\">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'><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_ce2518a84ba80d9896c1ff3726bb02a5' 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'><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_849113a40c6f0c75b873c62b596cc218' 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   aria-label=\"Have you suffered any pain in your ears within the last 30 days?\">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'><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_e96b67d07e864e79663bbd40445e768a' 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'><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_b42515fe6680aa6a51a13959c617697f' 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   aria-label=\"Pain level\">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'><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_395de11e3367f0a699b784d1940de3a2' 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'><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_ad23e266b6af4cd26ebb5fcb62c8ad3c' 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'><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_172b7efb673998397db0daf0942728d9' 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   aria-label=\"Are you aware of, or suspect you may have or have had a perforated ear drum?\">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'><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_390cbb973119392515f56ff586a11554' 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'><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_f3c939174dab1cdb2ab4c551dff90cd9' 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   aria-label=\"Have you tried to remove the wax yourself other than using ear drops?\">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'><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_9c6aab549958cb4b8e07fb197c8c749c' 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'><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_045aefe1a7d699fdfa23a7746126f8ac' 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   aria-label=\"Have you had any surgical operations on your ears, nose or throat?\">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'><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_9f55f784e3e809c480ba6a674938d677' 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'><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_3f96e4e6e4d4003336bd477e15e64622' 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   aria-label=\"Which one?\">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'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Left ear\"  id='checkbox_064ceaaeecc04f8a46f8832907e599f5' 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'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Right ear\"  id='checkbox_a771cf850f6e2723416f9b3637d9078e' 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'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Nose\"  id='checkbox_5cd8e4514bd0e86f403d0207097d5997' 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'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Throat\"  id='checkbox_23be723ee7241cd9a8647e492b20541e' 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' aria-label=\"How long ago? (Years, Months)\">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   aria-label=\"Are you currently under an ENT Consultant or receiving any treatment regarding your ears?\">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'><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_f299efad0079c5dbd511d00d8bcfa31f' 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'><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_2b1f7ca853178b73ecb6f5e668ea0174' 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' aria-label=\"Treatment Details\">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   aria-label=\"Are you using any antiplatelet or anticoagulant blood thinners? (E.g. Warfarin)\">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'><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_b854dca22426729839a4b59bdf4ddbce' 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'><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_7bcad0b0448862298f87fb2d7a097de0' 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' aria-label=\"Blood Thinner Details\">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   aria-label=\"Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?\">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'><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_18dc2d423577bd84fd9e0aee0e2c0c07' 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'><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_3f0e0c5e4aa95cef6ecf9d2b0d0fc7c9' 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   aria-label=\"Which ear\/s?\">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'><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_4addaad9110c90045e9a5070c6a5fff3' 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'><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_36a1f461e5923e0a5530285013c6d8ab' 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'><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_2e882a138712409bdecdab28015de7a5' 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   aria-label=\"Have you had wax removed from your ears previously?\">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'><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_c9b056723526d7d7c3872a256944465f' 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'><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_fb070d36da007a4f74d9e3628801bebb' 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'><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_1bf4ff796503d8aea086342e49076cd3' 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   aria-label=\"Do any of the following apply to you? (Optional - Tick if applicable)\">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'><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_51a470e27c01e2adde7cefc1f7a6172d' 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'><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_1d82f5ddf2a7a8535d4c8d5352f95687' 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'><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_be192058ee5f237780cc7cdf2457d383' 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'><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_81811a2efe296629e25d87e68864cfcb' 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_2\" ><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_3\" ><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_4\" ><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_5\" ><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' aria-label=\"Any details regarding the above\">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   aria-label=\"Are you aware of any reason as to why you should not proceed with microsuction or irrigation?\">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'><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_7c2990b65fa74b8cedca25ae49b9a4a4' 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'><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_b3f384ded11fbdcba432a85b78c04a22' 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_6\" ><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_7\" ><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\" 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' aria-label=\"Next of Kin Email Address\">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\" 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' aria-label=\"Next of Kin Phone Number\">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_8\" ><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\" 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\" 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   aria-label=\"Patient signature: (or signature of parent if under 16, guardian or attorney if appropriate)\">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\" 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