Ear Microsuction Form

Microsuction is a gentle, safe method for removing earwax using a specialised microscope and suction device. This technique avoids water flushing and is safer and often more comfortable, especially for those with ear conditions or a history of infections.

Please book an appointment for ear microsuction.

Download Consent Form

Patient Information

Ear Microsuction Patient Consent Form

Patient Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DOB

Date of Birth

Part 1

Does the patient have capacity?

Yes

Follow the Advance Care Directive (ACD), or if there is no ACD, obtain consent from the legal substitute medical treatment decision maker (MTDM).

Name of substitute MTDM

Category of MTDM

Part 2

Is an interpreter required?

Yes

Interpreter required

In-person

Telephone

Language

Name of interpreter

Signature

Part 3

Patient OR MTDM requests ear microsuction.

Clinician has explained the procedure, the risks associated with it and the alternatives.

Part 4b

Clinical Indication / Details (tick all relevant):

Itching sensation

Feeling of fullness

Hearing loss

Impacted wax

Tinnitus/other noises

Part 4a

Precautions identified

Details/other information:

Part 5

Ear drops (minimum 7 days for ear wax microsuction)

Clinician has explained how and when to administer wax softening ear drops, and provided the written Patient Information page with instructions.

Part 6

Costs for Ear Microsuction procedure

Fee payable $130

Pensioner $65

Our price is the same for the procedure, whether both or one ear is cleaned and/or proceedure does not proceed or is ceased for patient comfort +/- safety reasons not limited to patients inability to sit still, or is incomplete eg due to dryness of ear wax. A second fee payable will be charged if a repeat booking is required due to inadequate patient preparation and insuficient use of softening drops or if a repeat/additional proceedure becomes clinically indicated

Part 7

I acknowledge that the clinician has explained the “Ear Microsuction” procedure and provided me with the Patient Information. I was able to ask questions and raise concerns with the clinician. They explained the possible risks, benefits and alternatives available, Including:

Rare risk of damage to ear canal (trauma/grazing the outer ear or structures)
Rare risk of tympanic membrane perforation (rupture of the eardrum)
Occasionally, incomplete removal of wax or foreign body
Temporary vertigo (where a person feels as if they, or the objects around them, are moving when they are not, with dizziness/unsteadiness, nausea and or vomiting)
Discomfort, pain and or a cough.

I understand that:

I have the right to change my mind (withdraw consent) at any time, including after signing this form.
The out-of-pocket costs and know that a clinician other than the one consenting me might perform the treatment.
The cerumen microsuction procedure requires wax softening with drops for 7 days prior.
Many of the risks can be reduced by staying very still during the procedure. If I do need to move, I will tell my nurse (or raise my hand) so they can pause the procedure.
It is better if I have my eyes open during the procedure.
I should return to Andrew Place Clinic for assessment and possible treatment if I have concerns after my treatment.

I / MTDM have received the Patient Information titled ‘Ear Microsuction’. I agree to immediately tell the nurse (or raise my hand) during the procedure if I have any dizziness or discomfort, and/or if I have the need to move/cough: the procedure will pause. Informed (as above), I consent to having ear microsuction.

Patient Name

First Last

Patient DOB

Date of Birth

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Signature

MTDM Name

First Last

MTDM Signature

Clinician

First Last

Clinician Signature

Date

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Ear Microsuction Form

Ear Microsuction Form

Ear Microsuction Patient Consent Form

Part 1

Part 2

Part 3

Part 4b

Part 4a

Part 5

Part 6

Part 7

Your health starts here

Bundoora

Mill Park