Tel: 01329 448522

Home
Ear Wax Removal
Diabetes / Obesity
Videos
Contact Us

Book Session

Back to session list

Clinic: Fareham Innovation Centre

Session time: 11:00

Cost: £75.00

Do you have an existing account with us?

Yes No

Back

We are currently working to open up online bookings for returning clients, please contact us to book this session.

Back

Please enter your payment details:

Credit or debit card

Make Payment

Back

Consent Form

Please take the time to complete the form below.

If you have any questions regarding the form below, please do not hesitate to ask!

Customer Name

House Name

Street

Locality

Town

County

Postcode

Email Address

Mobile phone

Other phone

Date of Birth

GP Surgery

Have you had ear wax removed from your ears before?

Yes

Please provide details:

Which Ear needs wax removal:

Left

Right

Both

Do you suffer from any condition that causes balance problems or vertigo attacks?

Yes

Have you suffered from any pain in your ears in the last 30 days?

Yes

Please provide details:

Do you have a perforated ear drum?

Yes

Have you tried to remove the wax yourself?

Yes

Are you currently under an ENT consultant or receiving any treatment regarding your ears?

Yes

Are you currently using blood thinning/anti-coagulant medication (e.g. Warfarin)?

Yes

Are you aware of any reason as to why you should not proceed with microsuction?

Yes

How did you hear about our service?

Ear Wax Removal via Microsuction is considered safer than other methods, such as syringing. The Ear Wax Removal will be carried out by a trained clinician working to the protocols set out within the Ear Wax Removal Clinic's TM Aural Microsuction Procedures Manual. Complications of Ear Wax Removal that Microsuction are uncommon; however possible complications, side-effects and material risk 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 minimized, it is essential that accurate past medical history is supplied to our clinicians. In addition, it is important the patient remains still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding.

By agreeing to the Terms and Conditions above, you accept that you have read and understand the possible complications that may occur and agree that Barlowcollins Ltd., or any of its employees, cannot be held responsible for these.

I have read and understood these terms and conditions and am willing to be bound by them.

Statement of Consent:

I understand that personal information is held about me.
I have had the opportunity to discuss the implications of sharing or not sharing information about me.