Loading
HEARING ASSOCIATION WELLINGTON INC.
Persons name
First name
Last name
Date of Birth
Person or Household Address
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Cell phone
Home phone
Email address
Ethnicity
Māori
Pacific Islands
NZ European
European
Asian
Other
Prefer not to say
GP
Client Information and Consent
I confirm that I have notified my Ear Nurse of any and all relevant medical conditions and/or medications including infectious diseases.
I understand that all my records are confidential and governed by the Privacy Act. I understand that removal of earwax can involve minor risk. Microsuction is an invasive procedure that could, in very rare cases, cause complications which include tinnitus, balance problems, external ear infections or a perforated ear drum. Please follow the instructions given by the Nurse and be assured that every precaution is taken to prevent any complications.
Signature
Clear
FOR WELLINGTON HEARING STAFF ONLY
Date of procedure
Date
Follow up date
Submit
Please check the highlighted fields
✔
✘