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Microsuction Ear Wax Removal Consent Form

Please fill out the following form. To safely remove any wax or foreign bodies present 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 the following questions and tick the relevant boxes.
Do you suffer from any condition that causes balance or vertigo attacks?
Have you had any fluid discharge from your ear/s within the last 30 days?
Have you suffered any pain in your ear/s within the last 30 days?
Are you aware of, or suspect you may have a perforated ear drum?

Thanks for submitting!

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