Download Cerumen Management Cerumen Management

Cerumen Management
Patient Name______________________________ Date______________
DOB__________________
PCP_________________________
1.
2.
3.
4.
5.
6.
Have you used any ear wax softening agents?_________
Do you have a history of middle ear problem such as
ruptured ear drums, ear infections or surgeries
etc?__________________________________________
Are you diabetic?________________________________
Do you have ringing or buzzing in either ear? __________
Are you taking Coumadin or any other blood thinning
medications?____________________________________
Have you had cerumen removed before?______________
I am aware that Cerumen management is a non covered service and am aware
that I will be responsible for full payment of this service
Patient Signature___________________________ Date____________
Cerumen Management
Patient Name______________________________ Date__________
DOB______________
PCP_________________________
1. Have you used any ear wax softening agents?_________
2. Do you have a history of middle ear problem such as ruptured
ear drums, ear infections or surgeries
etc?__________________________________________
3. Are you diabetic?________________________________
4. Do you have ringing or buzzing in either ear? __________
5. Are you taking Coumadin or any other blood thinning
medications?____________________________________
6. Have you had cerumen removed before?______________