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Patient Information
To ensure that we provide you with the best possible care you must
complete our patient consent form p
rior to booking your appointment.
Patient's Full Name
Email Address
Address
Contact Number
Name of GP Surgery
Date of Birth
Do you suffer from any condition that may result in dizziness or balance problems ?
*
No
Yes
Are you using any anti-platelet or anti-coagulant blood thinning medication ?
*
No
Yes
Do you suffer from any condition that may cause or result in sudden movements ?
*
No
Yes
Are you currently under an ENT consultant regarding your ear/s ?
*
No
Yes
Have you had any surgical operations on your ears within the last 90 days ?
*
No
Yes
Do you currently have grommets in situ or removed within the last 90 days ?
*
No
Yes
Do you have persistent tinnitus or have an increased sensitivity to loud noises ?
*
No
Yes
Have you suffered from any pain in your ears within the last 90 days ?
*
No
Yes
Have you had an ear infection or any discharge from your ear/s within the last 90 days ?
*
No
Yes
Have you suffered from a perforated eardrum within the last 90 days ?
*
No
Yes
Have you had earwax removed previously ?
*
No
Yes
History of any complications from previous earwax removal procedures ?
*
No
Yes
Are you aware of any reasons as to why you cannot proceed with microsuction ?
*
No
Yes
Does Ear Wax Services have consent to contact your GP if required to do so ?
*
No
Yes
Submit the patient information and proceed to booking
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