Wax Removal – Intake and Consent Form

Please complete this form in advance of your booked appointment with us. It is important to complete all sections to the best of your ability in its entirety.

If you have any questions please feel free to contact us:

  • HRM Locations: 902 482-2222
  • Bridgewater: 902 530-2222
  • New Minas: 902 681-2222
  • Yarmouth: 902 742-2222
  • Toll Free: 1 877 988-4327

Wax Removal - Intake and Consent Form
How did you hear of us? *
Are you experiencing hearing loss in; *
Do you currently wear hearing aids? *
Are you experiencing any of the following; *
Do you have a history of any of the following; *
Are you currently taking any blood thinning or anticoagulant medications? *
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. *