Consent for ear syringing
Ear syringing is not risk free; therefore it is only carried out if the ear is completely blocked with ear wax. Partial blockage of the ear canal only requires irrigation if you wear a hearing aid or need a special examination.
Ear syringing can cause injury to the ears, ranging from minor infection, acute and chronic tinnitus (ringing in the ears), to perforation of the ear drum or deafness.
Contraindications to having ears syringed (people who cannot have this procedure), Please advise your doctor/nurse if you have had any of the following:
- Complications following previous ear syringing
- A Current ear infection or an infection within the last 6 weeks.
- Any previous ear surgery (apart from grommets which have come out 18 months ago)
- Grommets in Situ
- A current perforation or history of ear perforation
- A Cleft palate ( even if it has been repaired)
- Recurrent Otitis Externa ( inflammation of the external ear canal)
During the procedure
It can be uncomfortable to have your ears syringed but it should not be painful. If you experience any pain or dizziness during the procedure, tell the nurse immediately. It is important that the water is at a comfortable temperature, you must say if it is too hot or cold.
After the procedure
Rarely ear syringing can cause damage to the ear or ear drum. Therefore see a doctor after ear syringing if you:
- Develop ear pain
- Develop troublesome itch in the ear
- Develop a discharge from the ear
- Have swelling of the tissues around the ear canal ( which may indicate infection)
Ear care after irrigation
After you have had your ears syringed, keep them dry for a few days as the protective vax layer has been removed.
To keep the ears dry when you are washing your hair, place cotton wool which has been coated in petroleum jelly (vaseline) into the outside of the ear (not in the ear canal)
If you have continuing problems with ear wax, it may help putting in a few drops of olive oil once a week, to keep the wax soft and aid the natural movement of skin cells and wax.
Ear wax is a normal body secretion: it provides protection against infection and dust particles. The ear is self-cleaning, and the wax works its way out naturally. Never use cotton wool buds to clean inside your ears, as they irritate the delicate skin inside the ear canal, they will also push the wax back into the ear and compact it.
If you are unsure whether you wish to proceed with ear syringing, have ever had ear surgery or drum perforation or are concerned about the risks detailed above, please do not sign the consent form as you will need to discuss this with the doctor and nurse prior to giving consent.
Patient/Parental Consent to Ear Syringing
Procedure description:
Ear syringing (removal of ear wax from the ear) to remove impacted ear wax on the ear drum.
Risks of Procedure
- Damage to or perforation of the ear drum or middle ear
- Ear infection
- Pain, discomfort
- Dizziness/vertigo
- Light bleeding
- Nausea and vomiting
- Worsening of pre-existing chronic tinnitus.
Please note that this procedure does not always remove the wax
Signature of patient/person with parental responsibility for patient
I have received and read a copy of “consent for ear syringing” and understand and accept the risks associated with ear syringing. I agree that I do not have any of the conditions as detailed in the leaflet that may prevent me from undergoing ear syringing.
I agree to undergo this procedure.
Fee $150
Consent for Intravenous (IV) iron infusion
Common Side Effects (Occurs in 1-10% of cases):·
- Headache
- Flushing
- Nausea
- Low Blood phosphate levels
- Injection/infusion site reactions
Uncommon and Rare side effects (Occurs in <1% of cases):
- Hypersensitivity
- Numbness
- Increased heart rate
- Hypotension
- Difficulty breathing
- Taste disturbance
- Vomiting
- Dyspepsia
- Flatulence
- Abdominal pain
- Constipation
- Diarrhoea
- Itchiness
- Hives (urticaria)
- Redness (erythema)
- Rash
- Muscle pain or spasm
- Back, joint or chest pain
- Fever
- Fatigue
- Accumulation of fluid in periphery
- Pain and chills
- Anaphylaxis
- Rigors
- Malaise
Informed consent to receive Intravenous Iron Replacement Therapy
The patient understand that the administration of FERINJECT comes with the following risks, included
but not limited to:
- Anaphylactic reactions, which in rare cases may be potentially fatal
- Paravenous leakage- leakage in FERINJECT at injection site, potentially leading to long lasting skin discolouration
- Skin Irritations
- Headaches, light headiness
- Tachycardia, Hyper/Hypotension
- Nausea, Stomach pain, Constipation, Diarrhoea and Vomiting, Minor reactions to FERINJECT may last up to 48 hours post injection. For full list of reactions please see page 1.
- Understanding these risks, patient gives authority for staff of Metro Medical Centre to administer all necessary first aid and/or resuscitation measures, including alerting and ambulance and my emergency
contact, in the unlikely event that and adverse or anaphylactic reaction occurs.
As FERINJECT is not suitable for patients in some conditions, patient declares that none of the below listed is applicable:
- Pregnancy in the first trimester
- Dialysis
- Allergy to Ferric Carboxymaltose
- Iron overload/haemochromotis
- Under that age of 14 years
- Non-iron deficiency related anaemia
- Suffering from fever/sepsis
Signature of patient/person with parental responsibility for patient
I have received and read a copy of “consent for iron infusion” and understand and accept the risks associated with iron infusion. The patient has read the information provided on this consent. The patient understands that procedure is undertaken entirely at own risk and cost, and it requestion medical intervention in the form of Intravenous Iron Infusion.
Fee $200