Ear Irrigation Pre-Appointment Form

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Personal Details
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Your History

Before your appointment, we need to confirm some information about your medical history. We ask these questions so that we know it is safe to irrigate your ears. 
The information you submit will be added to your notes for the clinician performing the irrigation procedure to see ahead of your appointment

Please confirm

Privacy Consent

This form collects personal and medical information about you. We use this information to confirm you are registered with the practice and to allow the practice team to contact you if applicable. The information you send helps us to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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Last Reviewed 20/05/2024