eConsent (adult)

Do you have any allergies?*YesNo

Are you registered with a GP in the UK?*YesNo

Consent Statement

I 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, dizziness, injury to the ear canal or eardrum 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.

Signature