eConsent (child)

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, 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 child's ears.

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

Signature

Statement of InterpreterYesNo
LanguageLineFace-to-faceI 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.