< Buzz Ear Care – Consent Form

Buzz Ear Care – Consent Form

Client details

Full name Date of birth Address Phone number Email address

GP details

GP name GP practice GP phone

Medical history

Please tick any that apply: Perforated eardrum Previous ear surgery Recent ear infection History of dizziness/vertigo Tinnitus Hearing loss Blood-thinning medication (e.g. warfarin, aspirin) Other relevant medical conditions Details of any conditions or medications

Contraindications

I understand that if any of the above conditions are present, the practitioner may decide not to proceed with treatment or may recommend alternative management.

Procedures

Please tick the procedure(s) you are consenting to: Microsuction ear wax removal Irrigation / water-based ear wax removal

Risks & complications

I understand that, although every care is taken, ear wax removal procedures can carry risks, including but not limited to:

Discomfort or pain during or after the procedure
Temporary dizziness or imbalance
Temporary change in hearing or tinnitus
Minor bleeding in the ear canal
Ear infection
Very rarely, damage to the ear canal or eardrum

I have had the procedure explained to me and have had the opportunity to ask questions. I understand the risks and benefits and wish to proceed.

Aftercare advice

I understand that I should follow any aftercare advice given by the practitioner, including reporting any persistent pain, discharge, dizziness, or changes in hearing following the procedure.

Consent statements

I confirm that the information I have provided is accurate to the best of my knowledge. I consent to ear wax removal using the procedure(s) ticked above. I consent to Buzz Ear Care contacting me regarding my appointment and any follow-up if required.

Booking information

Booking reference (if applicable)

Signature

Client name (as signature) Date