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Parent / Legal Guardian Details

Consent Statement of Parent / Legal Guardian

I give permission for my child to undergo examination and treatment as explained and provided by auris ear care, which may include the following:

• Ear wax removal (microsuction)
• Removal of foreign body
• Treatment of ear infection

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 the fees associated with my treatment and I acknowledge that it is my responsibility to pay.

I understand that the services provided by auris ear care do not replace a complete medical assessment of my child's ears.

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