Booking Confirmation – Earwax.org.uk

Earwax.org.uk

38 Branch Locations
+44 330 808 1189
info@earwax.org.uk

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earwax.org.uk

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Thank you! Your booking is complete. An email with details of your booking has been sent to you.

Please complete the following consent form prior to attending your appointment.

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Full Name *

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Date Of Birth *

Do you suffer from any condition that causes balance problems or vertigo attacks? *

Have you suffered from any pain in your ears within the last 30 days? *

Do you have a perforated ear drum? *

Are you currently under ENT consultant or receiving any treatment regarding your ears? *

Are you currently using any anti-coagulants? E.g. Warfarin *

Are you currently suffering from hearing loss? *

How Did You Come Across Our Clinic? *

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By signing and submitting this consent form, you are agreeing to our company Terms and Conditions, you accept that you have read and understand the possible complications that may occur and agree that Park Medical Clinic or any of its employees, cannot be held responsible for these. I declare that I have read and understood these terms and conditions and am willing to be bound by them.

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