Ear syringing consent

HFGP Consent Form to Receive Ear Syringing

Patient Details

First name *

Surname *

Date of Birth *

All procedures have risks and side effects. It is important that you understand the specific side effects of any treatment.

Please read and cross the below statements to indicate that you have been told of these side effects and understand their implications.

Wax in the ears that causes symptoms can often be removed by gentle syringing with warm water. Whilst simple to do, it best done after softening the wax with wax softeners.

There can be some potential complications which are very uncommon. These include:

Perforation of the ear drum. If this fails to heal, it may require the need for surgical repair
Bruising and bleeding of the ear canal
Ulceration of the canal
Infection of the ear canal (otitis externa) or middle ear (otitis media)
Earache
Hearing loss
Ringing in the ears
Dizziness and nausea

I confirm I have read the above. My treating Doctor and Nurse has discussed with me the risks and the possibility of complications *

Syringing should not be done if you have:

A past or present perforation of the ear drum
Presence of a grommet
History of ear surgery
Hearing in one ear only

I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my doctor or nurse:

*

By signing this form, you confirm that:

Consent to having the syringing done by our trained nurses or your GP *

Understand that the syringing may not be successful *

Signature *

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Date *