HomeCovid-19 Ear Wax Removal Triage Form Covid-19 Ear Wax Removal Triage Form covid-19 microsuction ear wax removal online triage form Covid-19 Ear Wax Removal Triage Form Questions before ear wax removal in the age of Coronavirus COVID-19 Ear Wax Removal Triage Form PLEASE CAREFULLY READ THE FOLLOWING IMPORTANT INFORMATION On 1st June 2020, The British Society of Audiology, The British Academy of Audiology, and The British Society of Hearing Aid Audiologists, with input from ENT UK and The Infection Prevention Society, issued updated guidance on the safe provision of Audiology services, including ear wax removal, in the current context of CoVid-19. In compliance with "Audiology and otology guidance during Covid-19" issued by the above professional bodies, we must triage all patients, including existing ones, before booking their ear wax removal appointment. In order to protect everyone's safety, please read and answer the following questions carefully and truthfully. Failure to do so may put your health and that of our practitioners and other patients at risk. IMPORTANT: YOU WILL NEED TO BRING A MOBILE TELEPHONE WITH YOU WHEN YOU ATTEND YOUR APPOINTMENT. THIS FORM IS MOST EASILY FILLED IN ON A SMART PHONE OR TABLET In order to prevent you and another patient crossing paths, we will ask you to wait outside, away from the clinic entrance, while observing 2 metres social distancing from other people. This is easiest to achieve if you travel by car and wait in your car. If you have to come by public transport, for your own safety please try to observe 2 metres social distancing from other people as best as you can throughout your journey. We will call you on your mobile telephone when we are ready to see you, and will meet you at the door with a mask for you to put on. As space is limited in our clinic rooms, we regrettably cannot accommodate any extra people, so you (or the patient if you are booking for someone else) will need to be sufficiently mobile to be able to get in and out of the room on your own. If you have mobility problems and will struggle to get in and out of the room on your own, or are shielding at home, we are planning to offer a domiciliary service, but this is currently in the planning stage as it requires even more precautions to be taken on our part. Please fill in the form and you will be directed to a page where you can register on our list of people who need a home visit. Do You Understand The Introduction?*I have carefully read and understand the above introduction. I will bring a mobile telephone with me when I attend the appointment, and will wait outside until I am called.NoYesWhat Clinic Would You Like To Attend?*If you don't know the clinic, then enter the town or postcode where you are looking to get ear wax removal.Are you sufficiently mobile to get in and out of the clinic by yourself?*We can only accommodate one person, other than our practitioner, in the clinic room.Please choose...NoYesYour Ear Drum Is...*We are only able to offer ear wax removal services to people with an ear drum which is not perforated. Please confirm that you do not have a perforated ear drum (a hole in your ear drum). It is very important that you answer this question correctly, as if we find during the procedure that you have a perforated ear drum, we will have to evacuate the room for an hour, then deep clean it before it can be used again. We will have to ask you to leave immediately, cancel the next patient's appointment and you will be charged an additional £250. Is your ear drum perforated?Please Choose...PerforatedNot PerforatedAre You (Or The Patient If Booking For Someone Else) Over 18?*Are you (or the patient if you are booking on their behalf) over 18? If under 18, you will be directed to a booking page with practitioners who can treat under 18s.Please choose...Over 18Age 12 - 17Age 7 - 11Are You Shielding At Home?*Have you received a letter from the NHS saying you are extremely vulnerable to COVID-19 and must stay and home and shield from outside visitors, and are you STILL shielding? Currently we are only offering clinic appointments. We will be able to offer home visits in the near future, so please complete the form and we will direct you to a waiting list for a home visit.Please choose...Shielding At HomeNot Shielding At HomeAre You Taking Warfarin?*Warfarin is a blood thinning medicationPlease choose...YesNoYour Last INR ReadingHaving a high INR reading puts you at a greater risk of bleeding during an ear wax removal procedure. At the time, we require you to have an INR of 2.7 or below in order to book an appointment. Please choose...2.7 or lowerAbove 2.7Do You have Coronavirus?*Do you or anyone in your household have Coronavirus? Also known as CoVid-19 or SARS-CoV-2Please choose...YesNoDo You Have A New, Continuous Cough?*Do you have a new, continuous cough? Please choose...YesNoDo You Have A High Temperature?*Do you have a high temperature (37.8 degrees C or over)? If you do not have a thermometer, does your back or chest feel hot to the touch?Please choose...YesNoDo You Have A Recent Loss Of, Or Change To, Your Sense Of Smell Or Taste?*A loss of, or change to, your sense of smell or taste is now considered a possible early indicator of a CoVid-19 infection.Please choose...YesNoPeople in your household...*Does anyone in your household have a new, continuous cough, a high temperature, or a recent loss of or change to their sense of taste or smell?Please choose...DO have a new, continuous cough, a high temperature, or a loss of or change to their sense of tasteDO NOT have a new, continuous cough, a high temperature, or a loss of or change to their sense of tasteIs Your Ear Blockage Affecting Your Ability To Hear or Causing You Pain?*Due to the Coronavirus pandemic, our professional guidance requires that you have an audiological need, i.e. a hearing problem or pain in the ear. IT DOES NOT COVER ITCHY EARS OR UNUSUAL SENSATIONS.Please choose...YESNOTerms Of Booking - Appointment Fees*Our fees are for the appointment and cover our time and professional services. We will do our best to successfully perform ear wax removal, but regretfully we do not offer refunds if we are unable to perform a procedure because there is no wax or because you have not sufficiently softened it. Do you accept these terms?Please choose...YesNoTerms of Booking - Coronavirus Symptoms* IMPORTANT It is important that you have answered the above answers about Coronavirus, Cough, Temperature and Household correctly to the best of your knowledge. If you have active Coronavirus symptoms during your appointment, we will regrettably have to ask you to leave immediately and either self-isolate or seek medical attention. For the safety of our other patients, we will then have to evacuate the room for one hour, cancel the next patient's appointment, and deep clean the room. You will also be charged an additional £250. We hope you understand the necessity for these stringent measures, as they are there to protect you and our other patients. Do you accept these terms?Please choose...YESNOName*Please confirm your name First Last Email* Consent*COVID-19 You confirm that the answers you have given are correct and give your consent for us to store and process them as required to provide our service to you. I agree for the answers I have given to be stored and processed as necessary for the service to be provided, and confirm these answers to be correctSignature* After you click "Submit", you will go on to the next step. DO NOT click "BOOK NOW (GO TO TRIAGE FORM)" or you will be brought back here. At the very top of the booking page is a blue area with a box for you to enter your postcode. After entering your postcode, either hit enter or click "Find Appointments", and in about 5 seconds the available appointments will be displayed for you to choose.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.