Your details

These details are needed to register you as a new client.

Title*

Full name*

Contact number

Email address*

Date of birth*

GP surgery

Address line 1*

Address line 2

Town/City*

Postcode*

Do you have any mobility issues?*

YES
NO

Please tell us what we need to know about your mobility issues:

Your History

The answers you privide to the following questions will enable us to select the most suitable and safest method of wax removal for you.

Have you had wax removed from your ears previously?*

YES
NO

Would you like to give details?

Do you suffer from any condition that causes balance problems or vertigo attacks?*

YES
NO

Have you had a vertigo attack within the last 30 days?**

YES
NO

Have you suffered from any pain in your ears within the last 30 days?*

YES
NO

Do you have a current or suspected ear infection?*

YES
NO

Do you currently have any ear discharge?*

YES
NO

Do you have persistent tinnitus (usually a ringing or buzzing noise in the head or ears)?*

YES
NO

In which ear(s)?*

LEFT
RIGHT

Is the tinnitus made worse by noise exposure?*

YES
NO

Are you currently under an Ear Nose Throat Consultant or receiving any treatment regarding your ears?*

YES
NO

Do you suffer from Hyperacusis? (Hyperacusis is when everyday sounds seem much louder than they should)*

YES
NO

Have you had any operations on your ears?*

YES
NO

Would you like to give details?

Are you currently having radiotherapy?*

YES
NO

Are you currently using any anticoagulants - blood thinning drugs e.g. Warfarin, Apixaban, Aspirin?*

YES
NO

Do you currently have a perforation (hole in the eardrum) or a recently healed perforation?*

YES
NO

Are you diabetic?*

Yes
NO

Do you have Hepatitis B / MRSA / HIV / Covid-19 / Tuberculosis?*

YES
NO

Do you have a PVP (Programmable Ventriculo-peritoneal) shunt?*

YES
NO

Are you aware of any reason why you should not proceed with microsuction?*

YES
NO

Do you have any further comments regarding your ears or the wax removal treatment?*

YES
NO

Would you like to give details?

Please read the following

Wax removal via micro suction is considered safer than other methods such as syringing. Your ear wax removal will be performed by a trained clinician working to the protocols set out within The Tripp Hearing Aural Micro Suction Procedures Manual.

Complications of ear wax removal with microsuction are uncommon; however possible complications, side-effects and material risk inherent in the procedure include, but are not limited to:

damage to skin of the ear canal or the ear-drum during the procedure,
infection of the ear canal or other ear structures following the procedure,
temporary reduction in hearing,
permanent reduction in hearing,
temporary dizziness and (rarely) possible sickness or fainting,
triggering of new tinnitus or temporary aggravation of existing tinnitus,
temporary irritation to the throat, (especially if already dry, tickly or sensitive).

To ensure the risk of complication is minimised, it is essential that accurate past medical history is supplied to our clinicians. In addition, it is important the patient remains relatively still during the procedure as sudden movement may significantly increase the risk of ear drum perforation, permanent hearing loss and/or bleeding.

Microsuction is a system which effectively uses a vacuum to clear out any debris or wax from the ear canal. The CE marked suction unit is designed to remove fluids from the airway or respiratory support system and infectious materials from wounds. It has been adapted for the use of aural micro-suction. During microsuction, a fine suction tube is gently inserted into the ear canal while being viewed closely through a microscope or magnifying Loupe headsets. Sometimes, depending on the amount and consistency of the wax and your own comfort, it may not be possible to remove all the wax in one visit. If this situation occurs the Aural Care Practitioner will stop the procedure and you will be advised to continue to use a wax softener for a few days and return to have the remainder removed. There will be a charge for return visits.

Consent

I accept that I have read and understood the possible complications that may occur and agree that Tripp Hearing or any of its employees, cannot be held responsible for these. I give my consent to allow the Aural Care Practitioner to remove wax from my ear using the safest and most appropriate method for the amount and consistency of wax discovered. I agree to have the image of my ear recorded by a video otoscope during the procedure and give my consent for those images to be stored digitally in my clinical notes.*

EXTERNAL CLINICS

HEARING PROTECTION

HEARING AIDS REPROGRAMMING

AUDITORY TRAINING - LACE

EAR CHECKS

EAR IMPRESSIONS

PRICING

WAX REMOVAL

HEARING TESTS

HEARING AIDS

EAR IRRIGATION TRAINING

EXTERNAL CLINICS

HEARING PROTECTION

HEARING AIDS REPROGRAMMING

AUDITORY TRAINING - LACE

EAR CHECKS

EAR IMPRESSIONS

PRICING

A few questions..

Before your appointment, please complete the following questionnaire to help us select the most suitable and safest method of wax removal for you.

Your details

Your History

Please read the following

Consent