Please enable JavaScript in your browser to complete this form.Consent *Consent given to allow the wax removal procedure most appropriate. Understood small risk involved. Aware the procedure can be terminated at any time.Full Name of Client *Practitioner *Postcode *Date of Treatment *Fee Paid *1). Have you ever had wax removed from your ears previously *MicrosuctionEar Irrigation / SyringingOwn attemptsOtherNone2). Contra-indications to Microsuction (Please tick at least one and as many as apply - if none apply, tick none!) *Problems with microsuction previouslyHistory of severe dizzinessUnable to keep head still or prone to unpredictable movementsUndue sensitivity to loud noise (Hyperacusis)NoneDetail - Contra-Indications to Microsuction3). Contra-indications to Ear Irrigation *Problems with ear irrigation previouslyConfirmed middle ear infections within last 6 weeksRecent outer ear infection with pain / tenderness (Acute Otitis Externa)Cleft Palate (Repaired or not repaired)Perforated ear drum not healedDischarging ear within last yearEar Surgery (apart from grommets that have extruded at least 18 months previously and documented ear drum is intact)NoneDetail - Contra - Indications to Irrigation4). Precautions to Ear Irrigation *Previously perforated ear drum confirmed healed by GP / Hearing SpecialistProminent tinnitusImpaired immune system (Diabetes, HIV, Hepatitis etc)Balance problemsMedication - Anticoagulants (excluding aspirin) / high dose steroids / chemotherapyRadiotherapy of head / neck area (leading to potential thin delicate skin prone to trauma)NoneDetails - Precautions to Irrigation5). Other Contra-Indications and Precautions *Previous Head InjuriesAllergiesEar Protection WearerHearing Aid WearerUsing Cotton BudsOil AppliedNo OilPrevious History with ENTReason to not proceed?Tell us if in discomfort!Details - Other Contra - Indications and PrecautionsResults *Right Ear ClearedLeft Ear ClearedBoth Ears ClearedBoth Ears No WaxOlive Oil UsedSodium Bicarb UsedLess than 1 Week Applied> 1 Week Applied> 2 Weeks AppliedTM's VisibleHearing ImprovedTinnitus ImprovedClient HappyMicrosuction UsedIrrigation UsedDry Removal UsedFollow Up RequiredFollow Up BookedCase NotesSubmit
