eConsent (child)

Personal Details


YesNo


YesNo


YesNo


YesNo

GP Details

YesNo


Parent / Legal Guardian Details


Consent Statement of Parent / Legal Guardian

I give permission for my child to undergo 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 my child's 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 child's ears.

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

Signature

Relationship to Child*