eConsent (Adult) Patient DetailsFirst Name* First Last Name* Last HiddenD.O.B*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920D.O.B*Day12345678910111213141516171819202122232425262728293031Month*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Year2010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*FemaleMaleOtherPrefer not to sayEmail* Phone*Do you have any current medical conditions?* Yes No Enter DetailsAre you on any regular medication?* Yes No Enter DetailsDo you have any allergies?* Yes No Enter DetailsAre you registered with a GP in the UK?* Yes No GP Lookup* HiddenFull Name HiddenPractice Name* Hidden1st Line Address* Hidden2nd Line Address HiddenPostcode* Are you happy for Auris Ear Care to share the details of today's appointment with your GP?* Yes No Have you or any member of your household had any of the following symptoms in the last 2 weeks?*- high temperature - new, continuous cough - loss or change to your sense of smell or taste Yes No Please consider rebooking the appointment following your risk assessment.Consent StatementI consent to examination and microsuction treatment as explained and provided by Auris Ear Care, which may include the following: Ear wax removal Foreign body removal Ear infection treatment I understand the risks of treatment which include bleeding, ringing in the ears, hearing loss, dizziness, fainting or light-headedness, injury to the ear canal or eardrum, failure to improve symptoms or the need for further treatment. I understand that the services provided by Auris Ear Care do not replace a complete medical assessment of my ears. I understand the fees associated with my treatment and I acknowledge that it is my responsibility to pay.SignatureSignature*Signed by*---PatientHealthcare ProfessionalLasting Power of Attorney (LPA)RelativeFull Name* Interpreter (provided by LanguageLine)* Yes No Language I have interpreted the information above to the patient to the best of my ability and in a way in which I believe they can understand.HiddenInterpreter---In personLanguageLineHiddenFull Name HiddenSignature*Sign OffClinician*---Dr Riaz Rampuri (GMC 7494525)Dr Misha Verkerk (GMC 7304120)Location*HomeCare HomeHarley StreetHospitalHotelNursing HomeOffice / WorkplaceResidential HomeRetirement HomeOtherHow did you hear about us?*---AudiologistEmployerFacebookGoogle (Ads)Google (Maps)Google (Organic)Harley StreetInstagramNHS GPOn the RoadOtherPharmacistPrivate GPRepeatWord of Mouth I am happy to receive further communication from Auris Ear Care
