Ear Irrigation

If you have requested an appointment for ear syringing you must read this leaflet before the appointment and sign this consent form.

Agreement to Treatment - 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.

Please use format DD/MM/YYYY