The purpose of micro suction is to safely remove any excess wax within the ear canal.

It is important that the clinician is made aware of anything which may have a bearing on the procedure. Please answer these questions regarding your ear health, by discussing with your clinician or completing the form sent to you prior to procedure.

• Do you suffer from any condition that causes balance problems or vertigo attacks? Yes No

• Have you suffered from any pain in your ears within the last 30 days? Yes No

• Are you aware if you have a perforated ear drum? Yes No

If "Yes", which ear? Left Right How long ago did this occur? Year(s) Month(s)

• Have you tried to soften or remove the wax yourself other than using drops? Yes No

• Any symptoms of tinnitus? Yes/NO

• Cleft Palate repaired? Ramsey Hunt Syndrome ?

• Have you previously had microsuction or ear irrigation? Any issues?

• Discharge or infections in the last 30 days? Yes/No

• Have you had any surgical operations on your ears, nose or throat? Yes No

If "Yes", which ear? Left Right How long ago? Year(s) Month(s)

• Areyou currently under an ENT Consultant or receiving any treatment regarding your ears? Yes No

• Areyou using anticoagulants, e.g. Warfarin? Yes No

• Areyou aware of any reason as to why you should not proceed with micro suction? Yes No

• Have you had wax removed from your ears previously?

Ear wax removal via micro suction is considered safer than other methods such as syringing. The procedure will be

performed by a qualified trained clinician following guidelines written by The Hearing Lab & The British Society of

Audiology. Complications of ear wax removal with micro suction are uncommon; however possible complications,

sideeffects and material risks inherent in the procedure include but are not limited to: incomplete removal of ear wax

requiring a return visit (for severely impacted wax), minor bleeding, discomfort, ringing in the ear (tinnitus), perforation of

the ear drum and hearing loss.

To ensure the risk of complication is minimal, it is essential that accurate past medical history is supplied to our clinicians.

In addition, it is important that the patient remains relatively still during the procedure as sudden movement may

significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding. The CE marked suction

unit is to remove fluids from the airway or respiratory support system and infectious materials from wounds and has been

adapted for aural micro suction.By agreeing to these terms and conditions you accept that you have read and understandthe possible complications

that may occur and agree that Earlceanimg.uk / slaters ltd, or any of its employees, cannot not be held responsible for them. I have read and

understood the terms and conditions above and

am willing to be bound by them.