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EPS nomination form

Remote Earwax Removal Enquiry

Please fill out the following details below. We will respond to you with more details about the service as soon as possible.

First name

Email

Address

GP Surgery

Have you been advised to soften the wax?

Yes

No

Have you had an ear infection within the last 6 weeks?

Do you suffer with tinnitus? (ringing or buzzing in the ears)

Do you feel your hearing is being affected by the wax in your ears?

Have you suffered with any pain in your ears?

Last name

Date of Birth

Phone

Would you like your GP to be informed of this consultation?

Yes

No

Have you ever had wax removed previously?

Yes

No

Have you consulted your GP or a medically qualified professional?

Have you ever had, or do you have a history of dizziness?

Do you take any anti-coagulant medication? (blood-thinning medication)

Have you ever had, or do you have a perforated eardrum?

Please state if you have any other medical conditions.

Do you have access to a hand washing facility? (i.e Sink)

Yes

No

Do you have access to two chairs?

Yes

No

Please state if you have any drug or food allergies.

Are you able to sit in the chair for the service?

Yes

No

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

123 Commercial Road | Swindon | SN1 5PL

GPhC Registration number: 1038758

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