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Earwax Removal Consultation Form

Earwax Removal Consultation Form

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Name
Address

Medical History

1. Have you had earwax removed previously?
2. Have you been advised to soften the earwax (e.g. with olive oil/sodium bicarbonate)?
3. Have you had an ear infection within the last 6 weeks?
4. Have you recently consulted your GP/medically qualified professional?
5. Do you suffer from tinnitus (e.g. hearing noises or ringing in the ears)?
6. Do you suffer from vertigo or balance problems?
7. Have you suffered with any pain in your ears?
8. Are you experiencing any hearing impairment?
9. Are you using anticoagulant medication (e.g. blood thinners)?
10. Do you have a perforated ear drum (e.g. a hole or tear in the eardrum)?
11. Have you had surgery/operations on your ears/nose/throat?
12. Do you have current active eczema or psoriasis (e.g. causing pain, swelling, irritation or discharge) OR ear-canal inflammation?
13. Do you have a grommet fitted in the ear (e.g. a tiny ventilation tube inside the eardrum to prevent a build-up of fluid)?
14. Do you have any other medical conditions?
I have read and agree to the terms and conditions listed on the link above.

By agreeing to the above terms and conditions, you accept that you have read and understand the possible complications that may occur and agree that your chosen provider, or any of its employees, cannot be held responsible for them.

  • I understand that there may be small risks involved with wax removal but the ear clinician, based on my personal circumstances and case history, has discussed these risks with me.
  • I have notified the Ear Care Practitioner of all known conditions, medications or other factors that may affect my suitability for any or all forms of wax removal.
  • I give consent for images and videos of my ear(s) to be taken during the appointment
  • I understand my information will only be shared with Tympa Health Technologies Ltd who manage the Tympa System.
  • I acknowledge that this is a private service provided by the pharmacy and agree to pay prices as listed.
  • I hereby give the Clinical Ear Care Practitioner informed consent to remove wax from my ear(s) using the procedure identified as most appropriate for my personal circumstances.

I understand I can ask the clinician to stop the procedure at any time, for any reason.