This informed consent form is to provide written information regarding the risks, benefits, and alternatives of the procedure you are about to undertake. This material serves as a supplement to the discussion you have with your doctor/healthcare/medical provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form.
ABOUT THE PROCEDURE
Ear wax removal is a procedure performed to safely remove excess or impacted ear wax (cerumen) that may be causing symptoms such as hearing loss, discomfort, dizziness, or a sensation of fullness in the ear. The techniques used include microsuction and irrigation:
MICROSUCTION: This method uses a small, gentle suction device to carefully remove ear wax under direct visualisation with a specialised microscope or loupe.
IRRIGATION: This method involves flushing the ear canal with a controlled stream of warm water to dislodge and remove ear wax.
Both methods are safe, effective, and designed to minimise discomfort while addressing the symptoms caused by ear wax buildup.
RISKS AND COMPLICATIONS
Understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate medical attention and/or additional treatments. Risks include but are not limited to:
Temporary discomfort, pain, or tenderness in the treated ear.
Minor bleeding or irritation of the ear canal.
Temporary dizziness, vertigo, or imbalance during or after the procedure.
Tinnitus (ringing in the ears) or temporary worsening of tinnitus.
Risk of infection following the procedure.
Rare complications such as damage to the ear canal or eardrum, including perforation.
Residual wax or incomplete removal, requiring follow-up treatment.
PUBLICITY MATERIALS
I authorise the taking of clinical photographs and videos. I understand that photographs and videos may be taken of me for educational and marketing purposes. I hold the practitioner harmless for any liability resulting from this production. I waive my rights to any royalties, fees, and to inspect the finished production as well as advertising materials in conjunction with these photographs.
RESULTS
Ear wax removal using microsuction and irrigation is generally safe and effective. While the procedure often provides immediate relief from symptoms, results may vary depending on the severity of wax impaction and individual anatomy. There is no guarantee that all symptoms will be resolved, and additional treatments may be required if wax reaccumulates or symptoms persist.
POST-TREATMENT CARE
I have been instructed in and understand the post-treatment instructions. I understand that I may experience temporary mild discomfort, and I will monitor for signs of infection, such as increased pain, redness, or discharge, and report them to my healthcare provider promptly.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue treatment at any time. However, I acknowledge that payment for any treatments administered will still be required in full.
PAYMENT
I understand that this is an elective procedure and that payment is my responsibility and is expected at the time of treatment. I understand that this is a non-essential procedure and the procedure has been fully explained to me.
I certify by signing this form that I have read and understood the information provided in this document. All of my questions have been answered satisfactorily. I accept the risks and complications of the procedure, and I understand that no guarantees are implied regarding the outcome. I also confirm that I will notify my healthcare provider of any changes in my medical history.