I understand that ear wax removal cannot be performed if the eardrum is perforated (has a hole), there is an active infection in the ear or ear surgery was performed in the last six months. I have been recommended to use ear wax softening ear drops for at least 3 days before the ear wax removal appointment.

I understand that ear wax is normal and has a very important role to play in keeping the ears clean and healthy. Only excessive amount of wax requires removal. 
  
I have been notified that should the clinician believe the ear wax cannot be removed safely, he/she will stop the procedure.

Every possible precaution will be taken to avoid discomfort or adverse results during the removal procedure. I understand that ear wax removal involves minor risks such as small abrasions or minor bleeding. Dizziness and tinnitus may occur after earwax removal. Some rare abrasion or trauma such as perforation of the eardrum may occur. In the event of uncommon abrasion or trauma, I will be referred to my GP or ENT for treatment.  I have notified the clinician now present of any medications or conditions that could impact this procedure.

I understand that all records are confidential and governed by the Privacy Act.  I agree that the results of these tests be provided to the referring doctor as recorded in the consent form. Provision of results to any other person or agency will require my written consent.

By signing this form of consent, I am agreeing that I have been informed of the risks of ear wax management and would like to continue with the procedure. If  I decide that I  do not want to have your ear wax removed, at any time, I may stop the procedure.

Please complete payment at least 24hours before the appointment by credit card (sub-charge applies) or direct bank transfer as specified on your invoice. If due to unforeseen circumstances we need to cancel your appointment, a full refund will be provided. If no wax is removed or you decide you do not want to have your wax removed during the appointment, $70 refund will be provided. No Medicare rebate available for earwax removal appointment.