the care studio

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Consent for Treatment

Before any treatment can take place at the care studio, a treatment consent form must be completed and submitted.

The quickest and easiest way to do this is to complete the form below and submit it online before your arrival at the clinic - this means we start with your treatment straight away and we can get your ears back to their best as quick as possible!

If you have any questions, please feel free to email us or send a WhatsApp message to 07708 518511

and I'll get back to you as soon as I am able.

Consent to treatment at the care studio

Please fill out the following form in order to consent to

micro suction/irrigation ear wax removal by the care studio

Full name

Email address

Date of Birth required

Contact phone number

Home address

GP Surgery

Do we have your consent to contact your GP if necessary?

Yes

No

Please tick any that apply to you & agree to the statement of consent below

I suffer from a condition that causes balance problems or vertigo attacks

I have tinnitus (ringing in the ears)

I have suffered from pain in my ear(s) within the last 60 days

I have had in the past, or have got, a perforated eardrum (a hole or tear to the ear drum)

I am currently under an ENT consultant or receiving treatment regarding my ears

I am currently using an anti-coagulant (blood thinner) or insulin (for diabetes) or high dose steroids

I have had radiotherapy to the head or neck or immunosuppressed

I know of a reason why I should not proceed with micro-suction

Ear wax removal via microsuction is considered safer than other methods. Complications of microsuction 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 resulting in a return visit, minor bleeding, discomfort, ringing in the ear (tinnitus), perforation of the ear drum, and hearing loss. To minimise complication, an accurate past medical history must be supplied and it is important that the patient remains relatively still during the procedure as sudden movement may significantly increase a risk of ear drum perforation, permanent hearing loss, and/or bleeding. It should be noted that suction machines used for ear microsuction are used off licence.

By agreeing to the terms & conditions above, you accept that you have read and understand the possible complications and agree the care studio, or any of its employees, cannot be held responsible for any of these. I have read and understood these terms and conditions and am willing to be bound by them

Thanks for submitting!