Ear Irrigation Appointment Request Form

Section 1: Personal Details

First name

Last name

Email

Phone

Section 2: Appointment Preference

Preferred Appointment Type

Clinic Appointment

Home Visit

Preferred Day

Tuesday

Thursday

Saturday (Between 11am - 2pm)

Section 3: Ear Health Information

Which ear(s) would you like assessed? *

Section 4: Medical Safety Screening

Have you used olive oil drops within the last 5 days?

Do you currently have ear pain?

Have you had earwax removal before?

Have you ever had ear surgery?

Do you currently have ear discharge, or a suspected ear infection?

Do you have a history of perforated ear drum (e.g. a hole or tear in the eardrum)?

Do you have current active eczema or psoriasis (e.g. causing pain, swelling, irritation or discharge) OR ear-canal inflammation?

If yes, are you currently on treatment:

Do you have a grommet (a tiny ventilation tube inside the eardrum to prevent a build-up of fluid)?

If yes, how long has this been in place:

Do you have any other medical conditions?

If yes, please state the medical condition(s):

Section 5: Additional Information

Please provide any additional relevant information (e.g. symptoms, treatments, concerns).

Section 6: Consent

I understand this is an appointment request and treatment will only be carried out if clinically appropriate.

I consent to being contacted about my enquiry.

Please Note: All appointment requests will be reviewed and you will be contacted to discuss availability, suitability, and next steps before an appointment is confirmed.

A full written consent form will be completed and signed in person prior to treatment.