Ear Wax Consent Removal - Celtic Hearing, Hearing Aid Shop Swansea | Carmarthen

Do you suffer from any condition that causes balance problems or vertigo attacks?*

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

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

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

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

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

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

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

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

Have you had wax removed from your ears previously?*

Are you aware of any reason as to why you should not proceed with micro suction?*

Patient Name*

First Last

Patient Email*

Patient Telephone Number.*

Patient Signature*

Does the signature belong to the patient?*

Date of Signature*

Please select your preferred local branch of Celtic Hearing*

Consent*

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