Earwax Removal Form

TLES – Wax Removal History Form

Background Information

Title

First Name

Surname

Date of Birth

Sex

Postcode

Contact Number

Presenting Ear Complaint

Pain **

Leaking ***

Itching *

Blocked *

Reduced Hearing *

Ringing/Pulsing ** (if persistent after procedure and unilateral to see GP)

Dizzy ** (if persistent after procedure and

Previous Ear History

Recent Infection (in last 21 days) ***

Recurrent Infections **

Known Ear Perforation **

Previous Ear Surgery **

Previous wax removal (please state suction/irrigation/syringing)

Previous drop usage (please state which type and when)

Previous Cotton Bud Use **

Other (Please Comment)

Previous Medical History

Known medical conditions (please list)

Use of blood thinners (please state which ones) **

GP Details

GP Name

GP Surgery Name

GP Address

Key:
*Note and proceed accordingly
**Proceed with caution if comfortable
***Do not proceed, recommend patient seeks consult from GP

CONSENT FORM

TLES Endoscopic Earwax Removal

THE PROCEDURE

The aim of the procedure is to remove ear wax which is causing you issues. The aim is not to remove ALL the wax. Wax is NORMAL, NATURAL and NECESSARY, but too much of it can be problematic.

Your pharmacist will start by inserting a very narrow tube into your ear, this should not be painful. This tube contains a camera and light and is called an “otoendoscope”. It allows your pharmacist to clearly see if you have wax requiring removal. If you decide with your pharmacist to have the wax removed then this will be done under direct visualization with the otoendoscope, in combination with various wax removal instruments. Which instrument is used is dependent on the type and amount of wax you have in your ear canal. If a suction probe is chosen you will be able to hear a loud sucking noise, much like a mini vacuum cleaner. The other instruments do not emit a sound. There are no suction machines currently available for the intended use of wax removal, the suction machines used by your pharmacist is, however, widely used for this purpose.

During the procedure you should try and stay calm and as still as possible.

If you would like the pharmacist to stop the procedure please notify them immediately and the procedure will end.

If your pharmacist visualizes something in your ear which requires your GP to review, the procedure will end.

STATEMENT OF PATIENT/INTERPRETER/PERSON WITH LASTING POWER OF ATTORNEY FOR THE CLIENT:

I confirm I have read and understood this form.

I agree to the procedure described on this form and understand the steps.

I understand that the procedure may not result in alleviation of my symptoms as my symptoms may not be secondary to ear wax.

I understand the intended benefits and risks described in this form.

(FOR INTERPRETERS AND PERSONS WITH LASTING POWER OF ATTORNEY FOR THE CLIENT)

I have communicated the information above to the patient to the best of my ability and in a way, I believe s/he can understand.

I consent to clinical photographs/videos/audio recordings to be taken during the procedure. These may or may not be used as part of your case notes, in teaching forums or published (print, internet etc.)

Name (Type name for consent):

Date

Relationship to patient if not patient:

TLES – Wax Removal History Form

Background Information

Presenting Ear Complaint

Previous Ear History

Previous Medical History

GP Details

CONSENT FORM

TLES Endoscopic Earwax Removal

THE PROCEDURE

STATEMENT OF PATIENT/INTERPRETER/PERSON WITH LASTING POWER OF ATTORNEY FOR THE CLIENT:

(FOR INTERPRETERS AND PERSONS WITH LASTING POWER OF ATTORNEY FOR THE CLIENT)

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