Hearing Institute Atlantic — Wax Removal Intake Form

Name *

First

Name *

Middle

Name *

Last

Email *

Phone Number *

Address *

City *

Postal Code *

Date of Birth *

Family Doctor *

How did you hear of us? *

Are you experiencing hearing loss in; *

Left Ear

Right Ear

Both Ears

None

Do you currently wear hearing aids? *

Left Ear

Right Ear

Both Ears

None

Are you experiencing any of the following; *

Please provide a brief description of your symptoms.

Do you have a history of any of the following; *

Please list all current medications and associated medical conditions, include herbal medications and supplements; *

Are you currently taking any blood thinning or anticoagulant medications? *

Yes

No

If Yes, please list them.

Removing ear wax is something that should be done by a professional. It is not without risk. Certain risk factors may make it more likely for you to incur complications such as bleeding and irritation. These complications may occur even if you have no risk factors. The process of wax removal can involve discomfort although you should not experience pain. If you decide you do not want to have your ear wax removed, you can stop the procedure at any time. By signing this form of consent, you are agreeing to the procedure of wax removal, which will involve vacuum suctioning and could include curetting and/or irrigation. You are stating you understand the risks described above and wish to proceed. Should any such complication occur, you agree not to hold the audiologist responsible. You may wish to postpone signing this form until your questions are answered by your audiologist. Again, you may stop the procedure at any time. Thank you for taking the time to fill out this form. Your answers will allow your audiologist to provide the best in hearing health care for you. *

Agree

Disagree

Which location will you be visiting? *

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Wax Removal – Intake and Consent Form

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