Welcome to Expert Ear Care-Newcastle upon Tyne

Professional Ear Wax Removal—Clear ear wherever you are

Ear Wax Removal Consent Form

Please complete this form prior to your appointment. This form ensures you are suitable for treatment and helps us tailor your care to your medical history.

Name

Postcode

Contact Number

Date of Birth

Name of GP Surgery

Have you had ear wax removal before?

Yes No

Have you ever had any complications during previous wax removal?

Yes No

Do you have tinnitus?

Yes No

Currently experiencing vertigo or dizziness?

Yes No

History of ear/nose/throat surgery?

Yes No

Taking blood-thinning medication?

Yes No

History of vasovagal syncope/fainting?

Yes No

Do you suffer from dizziness or balance problems?

Yes No

Do you suffer from conditions that may cause sudden movements? (e.g., epilepsy, Parkinson’s)

Yes No

Are you currently under an ENT consultant regarding your ears?

Yes No

Have you had any ear infections or ear discharge in the last 90 days?

Yes No

Have you had a perforated eardrum before?

Yes No

Are you aware of any reason why you cannot undergo micro suction?

Yes No

Do we have your consent to contact your GP if necessary?

Potential Risks of Earwax Removal

The following risks have been explained to me, and I understand that while uncommon, they are possible:

Minor discomfort or sensitivity during the procedure
Temporary hearing changes or dizziness
Bleeding, inflammation, or infection
Worsening of tinnitus (ringing in the ear)
Injury to the ear canal or eardrum (rare)

Benefits

Ear wax removal may improve symptoms associated with wax impaction, including hearing loss, earache, discomfort, blocked sensation, tinnitus, vertigo, itchiness, and aid hearing aid function. However, symptom improvement depends on individual health factors.

Treatment Consent

I confirm I have provided full and accurate details of my medical history.

I understand the nature of the proposed treatment and that the procedure will be performed by a qualified practitioner.

I understand that if the procedure cannot be safely performed, it may be declined or deferred.

I consent to the use of the method deemed most appropriate by the practitioner (micro suction, irrigation, or manual).

I consent to the capture of clinical images/videos if necessary for treatment documentation or monitoring.

I consent to my data being stored securely in accordance with data protection legislation and shared only when necessary for clinical reasons.

Patient Declaration

By signing below, I confirm that I understand and agree to the terms of this consent and am willing to proceed.

Patient Signature

Privacy Notice:

We respect your privacy. All personal information submitted through this form will be kept confidential and used solely to manage your appointment and respond to your enquiry, in accordance with our Privacy Policy and GDPR guidelines.

At Expert Ear Care, we are committed to protecting your personal data. This policy outlines how we collect, use, and safeguard any information you provide when using our website or booking services.

What We Collect

We may collect the following:

Name and contact details (email, phone)
Appointment information
Medical concerns relevant to ear care

How We Use It

To confirm and manage appointments
To respond to your enquiries
To improve our services and patient care

Data Protection

We will never sell or share your data with third parties without your consent. All data is stored securely and processed in accordance with UK GDPR regulations.

Your Rights

You have the right to access, correct, or request deletion of your data at any time. Please contact us at [your email address] for any concerns.

Cookies

This website may use cookies to improve user experience and website functionality.

Welcome to Expert Ear Care-Newcastle upon Tyne

Ear Wax Removal Consent Form

Potential Risks of Earwax Removal

Benefits

Treatment Consent

Patient Declaration

Privacy Notice:

What We Collect

How We Use It

Data Protection

Your Rights

Cookies

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