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TERMS AND CONDITIONS OF SERVICE FORM

We kindly ask that you complete the form below prior to booking your service, or if you prefer this can be completed face to face, but we will go over the questions when you arrive. This step is important as it allows us to gather all the necessary information to ensure that we can provide you with the best possible experience. Your cooperation in this matter is greatly appreciated, and we thank you for taking the time to help us serve you better!

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Once you have completed the form, please click on the 'Schedule Appointment' button below. You can then choose the clinic location you would like to visit: Seymour in Morden, First Care Pharmacy in Thames Reach, or the Marven Surgery in Lupus Street Pimlico. Thank you for choosing us!

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COMFORTS HEARING

TERMS AND CONDITIONS OF SERVICE

Ear Wax Removal by Micro-suction:


At Comforts Hearing our costs are from £45 ear wax removal for one ear and £80 for two ear wax removal. We also provide a detailed report with images of the eardrum and canal.


There will be circumstances where stubborn wax cannot be removed and advice will be given to administer olive oil, if appliable, in the ear to soften the ear wax. In these circumstances, another appointment will be made. If you return within four weeks of the wax removal appointment (not an ear health check), depending on whether you have followed instructions to administer olive oil, you will not be charged for a further appointment. Please note ear wax removal is different from a ear helath check and each have their own cost.


If a further appointment is made to remove the stubborn ear wax.  This will be a new appointment and will be charged at the current rate of either from £45 for one ear or £80 for two ears. This is due to our time and resources.


Ear Health Checks:

We also provide a complete ear health check which costs £30 for one or both ears. This involves a physical examination of the ear using an Otoscope and a video Otoscope which takes pictures and video of the ear canal. We look for signs of infection, fluid build-up or abnomalities. We also provide a detailed report with images of the eardrum and canal. Please note an ear check is different from an ear wax removal session and each have their own cost.


Hearing Test: £65.

After your hearing test, you will receive your test results immediately and our hearing care specialist will review them with you, explaining their significance. If you have a hearing impairment, our specialist will assist you in selecting the most suitable hearing aid solution for your needs and lifestyle. If you choose hearing aids with us, we will schedule a follow-up appointment (usually within two weeks) to fit your new hearing aids. Custom-made hearing aids that fit your ear canal may take slightly longer to be ready.


Patient Information:

To safely remove any wax or foreign bodies present within the ear canal, it is important that the clinician is made fully aware of anything which may have a bearing on the procedure.

Your ear wax removal will be carried out by a trained clinician working to industry standard protocols. Wax removal may be done via micro-suction, irrigation /syringing, and/or dry tool extraction – whichever the clinician deems most appropriate based on the wax you present and your answers to this form.


Incidents during ear wax removal are very uncommon. However, Minor complications that can occur, which are deemed acceptable, include minor nicks or scratches to the ear canal, which can also lead to minor bleeding, soreness, mild discomfort and short-term ringing in the ear (tinnitus).

To minimise such risk please immediately notify the clinician of any discomfort or sensitivity to the increased sound level. Ear wax removal can cause slight dizziness in certain circumstances - the client should inform the clinician if they feel dizzy and the procedure should be paused until the client feels stable.


A more serious risk of damage to the ear canal or ear drum can occur if the client does not remain adequately still. Clients should inform the clinician of any discomfort or likely sudden movements, for example, if likely to sneeze or cough. All equipment is sterilised or is single-use only to keep infection risk to a minimum; however, there is always a risk that infection can set in once the client leaves the premises. Please contact the clinician for a free follow-up visit should you experience any discomfort of worrying pain, discomfort, swelling or discharge etc.

Please answer the following quesitons regarding your ear health below, prior to booking your appointment.

Have you had any infection in the last seven days and are you on any antibiotics?
Yes
No
Do you experience any condition that causes balance problems or vertigo attacks?
Yes
No
Have you had any balance issues or vertgo attacks in the last 30 days?
Yes
No

Notice

If you answered yes to the above question. If you begin to feel even the slightest bit dizzy or faint during the procedure it is important that you let the clinician know at the very first sign.

Have you had any fluid discharge from your ear(s) within the last 30 days?
Yes
No
Have you experienced any pain in your ears within the last 30 days?
Yes
No
Please describe the pain level if you have answered yes to the above question.
Slight
Significant
Excruciating
None of the above
Are you aware of, or suspect that you may have a perforated eardrum?
Yes
No
If you have answered yes to the above question, please state which ear.
Left
Right
Both
Have you tried to remove the wax yourself other than using ear drops?
Yes
No
Have you had any surgical operations on your ears, nose or throat?
Yes
No
Are you currently under an ENT Consultant or receiving any treatment regarding your ears?
Yes
No
Are you using any anti-platelet or anticoagulant blood thinners?
Yes
No
Do you have persistant Tinnitus (Usually a ringing or a buzzing noise in the ear(s)?
Yes
No
Which ear, if yes to the above question?
Left
Right
Both
Have you had wax removed from your ears previously?
Yes by Micro suction
Yes by other
No
Are you happy for Comforts Hearing to take pictures/video of your ear canal and eardrum. This is to be stored for our records or shared with your GP?
Yes
No
If a referral is required, do you consent to your ear health, pictures and videos being shared with your GP and other relevant health services?
Yes
No
I have completed this form to the best of my knowledge and agree to these terms of service?
Yes
No
I have read and understood the terms of service and am willing to be bound by them?
Yes
No
Does the patient understand the relevant information?
Yes
No
Birthday
Does the electronic signature above, belong to the patient?
Yes
No
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