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

If you are human, leave this field blank.

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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