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Ear Wax Removal Consent Form

Collect a patient's informed consent and relevant medical history before performing an ear wax removal procedure.

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Patient Name

First Name

Last Name

Appointment Date

Reason for Visit

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

Yes No

Have you had a vertigo (rotational dizziness) attack within the last 30 days?

Yes No

Have you suffered any ear pain within the last 30 days?

Yes No

Do you have a perforated eardrum?

Yes No

Have you tried to remove the wax yourself?

Yes No

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

Yes No

Are you currently under the care of an ENT consultant or receiving ear treatment?

Yes No

Are you taking anticoagulants (blood-thinning medication), e.g. Warfarin?

Yes No

Are you aware of any reason why you should not proceed with microsuction?

Yes No

Have you had ear wax removed previously?

Yes No

Patient's Signature

Sign here

Clinician's Signature

Sign here

Date Signed

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