Medical History & Consent form

To book an appointment, please fill out the below fields, then click next – you will then be redirected to our booking form.

Ear Wax Removal – Medical History & Consent Form (NICE NG98 Compliant)

First Name

Last Name

Date of Birth

Phone no.

Address

Address Line 1

Address Line 2

City

County

Post Code

Previous ear surgery

Known perforation of the eardrum

Recurrent ear infections / chronic Otitis Externa

Recent cold, sinus infection, or upper respiratory infection

Vertigo or dizziness (past or current)

Hearing loss (sudden or long-term)

Tinnitus (ringing in the ears)

Pain on touching or pulling the ear

Comments