ONLINE CONSENT FORM

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Full Name *

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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.

By signing and submitting this consent form, you are agreeing to our company Terms and Conditions, you accept that you have read and understand the possible complications that may occur and agree that Park Medical Clinic or any of its employees, cannot be held responsible for these.I declare that I have read and understood these terms and conditions and am willing to be bound by them.