Consent Form - Hearing Expert Clinic

Full Name *

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

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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GDPR Agreement *

I consent to having this clinic my submitted information so they can offer me the most appropriate level of care.

ONLINE CONSENT FORM