Most ear wax removal consent forms start life as a Word document someone else wrote, edited three times, printed on a clipboard, and read by patients in a waiting room while they are wondering whether they parked legally.
This is a better starting point: a complete consent form for private microsuction and ear wax removal, written for UK practitioners in aural care. It is 18 questions across four sections, in plain English, and a patient can get through it on a phone in about three minutes. Copy it, change it to fit how you work, and use it however you take bookings.
It pairs with our guide to setting up online booking as an ear wax removal practitioner, which explains why the consent form belongs in the booking itself.
Read this before you copy anything
This template is a writing aid, not a clinical protocol. What you screen for, what you refuse to treat, and what you refer on are set by your own training and scope of practice, your professional body’s current guidance, NICE’s guideline on hearing loss in adults (NG98, which covers ear wax removal), and what your indemnity insurer expects you to have documented.
So treat every question below as a prompt. Delete what does not apply to you. Add what your training tells you is missing. If your insurer gives you wording, their wording wins.
How the form is laid out
Four short sections, each with a heading and a sentence saying why it is there:
| Section | What it does |
|---|---|
| About your appointment | Sets expectations and catches anyone who should not book at all |
| Your ear health | The screening questions |
| Things that help us prepare | Practical detail that changes how the appointment runs |
| Your consent | What you are agreeing to, and a signature |
The headings matter more than they look. A patient faced with a long unbroken list of questions skims. A patient who can see they are on section three of four keeps reading.
The template
Section 1: About your appointment
Please answer these questions honestly. They help us make sure ear wax removal is safe and suitable for you before you travel. If an answer means we need to speak to you first, we will contact you before your appointment.
Please do not book, and seek medical advice today, if you have: sudden hearing loss in one or both ears, severe ear pain, a high temperature with ear pain, or bleeding from the ear. Contact your GP or call NHS 111.
That second paragraph is doing real work. A patient with sudden hearing loss needs same-day medical assessment, not a microsuction slot on Thursday, and the booking page is the last point at which you can tell them.
- Which ear or ears are you booking for? (choose one: Left / Right / Both / Not sure)
- Have you had your ears checked or wax removed before? (Yes / No)
- If yes, was there any problem during or after it? (free text)
Section 2: Your ear health
These questions are about things that can make ear wax removal unsafe, or mean it needs to be done differently. A “yes” does not necessarily mean we cannot see you.
- Have you ever had a perforated (burst) eardrum? (Yes / No / Not sure)
- Have you ever had surgery on your ears, including grommets? (Yes / No)
- Do you currently have an ear infection, or have you had one in the last six weeks? (Yes / No / Not sure)
- Do you have any discharge or fluid coming from either ear? (Yes / No)
- Do you have pain in either ear at the moment? (Yes / No)
- Do you have hearing in only one ear? (Yes / No)
- Do you get dizziness, vertigo or balance problems? (Yes / No)
- Do you have tinnitus (ringing, buzzing or other noises in your ears)? (Yes / No)
- Do you take blood-thinning medication, such as warfarin, apixaban or daily aspirin? (Yes / No / Not sure)
- Is there anything else about your ears or general health we should know? (free text)
A few notes on why these are worded the way they are:
- “Burst” next to “perforated”. Plenty of patients have been told they had a perforated eardrum as a child and never heard the word again. Give them the everyday word too.
- “Not sure” is a real answer. Forcing a yes or no on someone who genuinely does not know gets you a guess, and a guess on a perforation question is worse than an honest “not sure” you can follow up on.
- Name the medication. “Anticoagulants” gets a blank look. “Warfarin, apixaban or daily aspirin” gets a truthful answer.
- One free-text box, at the end. It catches what a fixed list misses without turning every question into an essay.
Section 3: Things that help us prepare
None of these affect whether we can see you. They help the appointment go smoothly.
- Have you been using ear drops or olive oil, and for how long? (choose one: Not using any / Less than 3 days / 3 to 7 days / More than a week)
- Do you wear hearing aids? (Yes / No)
- Is there anything that would make it hard for you to sit still for 20 to 30 minutes, or anything else we can do to make your visit easier? (free text)
Ask about drops in ranges, not dates. Nobody remembers the day they started, and a range is all you need to decide whether a visit is likely to be a short one.
Section 4: Your consent
Ear wax removal is a very common and usually comfortable procedure. Like any procedure, it carries some risks. During or after it you may notice temporary noise, dizziness, discomfort or a change in tinnitus. Less often, there may be minor irritation or bleeding of the ear canal. Rarely, the eardrum can be damaged. Sometimes wax is too hard to remove in one visit and a further appointment, or a period of using drops, is needed.
You can ask us to stop at any point during the procedure.
- I have read the information above, I have answered these questions truthfully, and I consent to ear wax removal. (consent checkbox)
- Signature (type your full name)
Keep the risk wording in the form rather than in a separate leaflet. The moment of booking is the moment a patient actually reads it, and what they read is then part of the record of what they agreed to.
One thing this form is not: your privacy notice
It is not your data protection notice, and it should not ask patients to “consent” to you holding their health information.
Consent to a procedure and your lawful basis for processing health data are different things under UK GDPR, and for most practitioners providing care, the basis for keeping records is not the patient’s consent. Mixing the two into one tickbox muddles both. Link your privacy notice from your booking page instead, and check the ICO’s guidance for health and care providers if you are unsure.
Three habits that make it work
However you run it, these make a consent form earn its place:
- Get it answered before the visit, not at the door. A contraindication found in the waiting room still costs you the timeslot.
- Read the answers the evening before a clinic. It takes five minutes and it is the difference between a phone call on Wednesday and an awkward conversation on Thursday.
- Review the form every year, and whenever your professional body or insurer updates its guidance. Date the version you are using.
How it maps onto Praxbook
Praxbook was built around exactly this form. Each service has its own consent form, and this template maps onto it directly:
| In the template | In the form builder |
|---|---|
| The four sections and their paragraphs | Section heading |
| Yes / No questions | Yes / No |
| Questions with a “Not sure” answer, the ear choice, and the drops question | Choose one, with the answers as its options |
| Q3, Q13 and Q16 | Free text |
| Q17 | Consent checkbox |
| Q18 | Signature |
Patients complete it as part of booking online, before the timeslot is reserved. If you book someone in by phone, the confirmation and reminder emails they already get include a link to complete it from their own account before the visit. Anyone who still has not can complete it on your device when they arrive. Each submission is kept on the appointment with the exact wording the patient saw, including the section text, so changing next year’s form never rewrites last year’s record.
It is free for 30 days with no card, and early access pricing is limited to the first 50 practitioners and locked for life.