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Health Questionnaire & Consent

Please fill out and submit the form below prior to attending your treatment

Which ear requires treatment ? Required
Have you suffered with any pain in your ears in the last 30 days ?
Do you have or ever had a perforated ear drum ?
Do you suffer from Tinnitus ?
Do you suffer from any condition that causes balance problems or vertigo ?
Do you suffer from Hyperacusis (a condition where every day sounds seem much louder than they should) ?
Are you currently undergoing Radiotherapy ?
Are you Diabetic ?
Are you currently wearing hearing aids ?
Do you struggle with your hearing ?
Are you currently under an ENT consultant or receiving any treatment regarding your ears ?
Are you currently on any blood thinners e.g. Warfarin, Apixaban, Aspirin , etc ?
Have you had ear wax removed previously ?
Have you tried to remove the ear wax yourself?
Are you aware of any reason as to why you should not proceed with micro-suction/water irrigation ?
Do we have your consent to send your GP a record of completion ?
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