At the bottom of following T&C's . Please complete your answers on this form.
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Any Easi Ear clinic is governed by these terms and conditions:

Wax removal via micro-suction is considered safer than other methods such as syringing. The wax removal will be carried out by a trained clinician working to the protocols set out within the Ear Wax Removal Clinic’s™ Aural Micro Suction Procedures Manual. Complications of ear wax removal with micro suction are uncommon; however possible complications, side-effects 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 minimised, 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.

Hearing tests and/or Tinnitus advice sessions are equally governed.

By agreeing to these terms and conditions you accept that you have read and understand the possible complications that may occur and agree that Easi Ear Hearing Care audiologists, or any of its employees, cannot be held responsible for them.

I have read & understood the terms & conditions above; I am willing to be bound by them and accept that my details will be stored electronically & on paper and kept safely. I agree that I can be contacted by Easi-Ear if & when necessary. I agree to pay the current full fee for the consultation [whatever the outcome; secondary visits at £25 if within 6 weeks of initial appointment] plus £30 if it is a home visit.

Where a red * is shown with a question, it means it is a required response.


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Email *
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Your signature: [Tick box if you accept all terms & conditions and that all answers are accurate] *
Your name *
Your Address & Postcode                                                 *
In the last 14 days have you had a temperature of 38C+? *
In the last 14 days have you had a loss of taste and/or smell? *
In the last 14 days have you had a runny nose / congestion? *
In the last 14 days have you had nausea and diarrhoea? *
In the last 14 days have you had a sore throat? *
In the last 14 days have you had extreme fatigue and/or muscle & body aches? *
In the last 14 days have you had a persistent dry cough? *
Have you had Covid-19? *
Do you currently have a perforation of your ear? *
Do you suffer from any condition that causes balance problems or vertigo attacks? *
Have you had a vertigo attack within the last 30 days? *
Have you suffered from any pain in your ears within the last 30 days? *
Have you suffered any Tinnitus/Ear noises in the last 30 days? *
Are you receiving medical treatment for your ears from an ENT Consultant or GP? *
Are you using anticoagulants, e.g. Warfarin, Apixaban, Aspirin etc? *
Is there any reason why you should not proceed with micro suction? *
Name & address:
Post code:
Best contact number: *
Date of birth: *
Name of GP’s Surgery: *
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