Cerumen Removal Consent Form

Your hearing healthcare specialist may decide it would be best to remove ear
wax from your ear canal.

Removing ear wax is something that should be done by a professional. Every
precaution possible will be taken to avoid discomfort or adverse results.
Complications and side effects of cerumen removal are rare and may include:

• Cerumen remains: If your hearing healthcare specialist is unable to
  remove the cerumen, you will be directed to see your primary care provider
  or otolaryngologist (ENT) for further treatment.
• Discomfort: Some people may feel mild to moderate discomfort during
  the procedure.
• Dizziness: Some people may feel lightheaded after the procedure. You
  will sit with our provider after the procedure to insure that dizziness has
  passed before being dismissed.
• Injury to the ear canal: Abrasions to the ear canal may occur during
  cerumen removal. Some bleeding may occur during the procedure. Bleeding is
  usually slight and resolves on its own.

If you decide you do not want to have your wax removed at any time, you may
stop the procedure.

I have been informed of my condition and consent is hereby
voluntarily given for cerumen (Earwax) removal.