Ear irrigation

Agreement to Treatment – Ear Irrigation

I agree to have my ears irrigated & have read ‘Patient information for Ear Irrigation’ & understand the contraindications & accept the risks.

I confirm I do not have any of the conditions listed in the leaflet that would prevent me safely having ear irrigation.

I understand the person performing the procedure will have appropriate training & experience.

Signature:

Name (print)

Date of Birth:

Please use format DD/MM/YYYY

Date:

Email Address:

Please specify the ethnic group the patient belongs to: *

Please specify: *

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