Ear wax removal booking form Name * First Name Last Name Date of birth MM DD YYYY Telephone Number * Email * Have you had wax removed from your ears before? Yes - Microsuction Yes - Irrigation / Syringing Yes - Own attempts No Do any of the following cautions to microsuction apply to you? Problems with microsuction previously History of severe dizziness Unable to keep head still for procedure Undue sensitivity to loud noise None Do any of the following cautions to ear irrigation apply to you? Problems with ear irrigation previously Confirmed middle ear infection within the past 6 weeks Recent outer ear infection with pain/tenderness Ear surgery Cleft palate Perforated ear drum not healed Discharge from ear within the last year None Please confirm if any of the following apply? Allergies e.g. hayfever, dust allergy Use cotton buds Have used olive oil ear drops Hearing aid wearer Ear protection wearer Previous history of ear/nose/throat problems Recent head injury Hepatitis, HIV None How did you hear about us? Thank you for contacting Pharmacy Cube. A Specialist Pharmacist will review your information and contact you within 24 hours to confirm your booking.Pharmacy Cube1A Kingsley GardensLondon, E4 8JS0203 662 0722Info@pharmacycube.co.ukhttps://pharmacycube02036620722.as.me/?appointmentType=68869253