eConsent (Child) Patient DetailsFirst Name* First Last Name* Last HiddenD.O.B*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920D.O.B*Day12345678910111213141516171819202122232425262728293031Month*MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberYear*Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001Gender*FemaleMaleOtherPrefer not to sayDoes your child have any current medical conditions?* Yes No Enter DetailsIs your child on any regular medication?* Yes No Enter DetailsDoes your child have any allergies?* Yes No Enter DetailsIs your child 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 Has your child 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 child’s risk assessment.Parent / Legal Guardian DetailsFirst Name* First Last Name* Last Email* Phone*Consent Statement of Parent / Legal GuardianI 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 of Parent / Legal GuardianSignature*HiddenSigned by*---Parent or GuardianHealthcare ProfessionalLasting Power of Attorney (LPA)Full 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 OffRelationship to Child*FatherLegal GuardianMotherClinician*---Dr Riaz Rampuri (GMC 7494525)Dr Misha Verkerk (GMC 7304120)Location*HomeHarley StreetHospitalHotelOtherHow 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
