EENT Earmold Impression Waiver – Online Form

Please fill up the following form

Patient’s Name

Date of Birth

Date of Service:

Ear(s)

Left Right Both

PROCEDURE DESCRIPTION

An earmold impression is a mold of the ear canal and outer ear used to fabricate custom hearing aids, earmolds, hearing protection, or other custom devices. The procedure involves placing a small foam or cotton block (a “dam”) in the ear canal, then injecting a soft, quick setting impression material into the canal and concha. The material sets within a few minutes and is then gently removed by the audiologist.

RISKS & POTENTIAL COMPLICATIONS

Temporary discomfort, pressure, or fullness in the ear
Minor irritation or redness of the ear canal skin
Allergic reaction to the impression material
Temporary reduction in hearing or sensation of blockage
Dizziness or lightheadedness during or after the procedure
Injury to the ear canal or eardrum, including perforation (rare), particularly in narrow or scarred canals
Impression material becoming lodged in the ear canal, requiring medical removal (rare)

PRE IMPRESSION SCREENING (STAFF USE)

No ear surgery within the past 6 weeks No known eardrum perforation or PE tubes present No active ear infection, drainage, or significant pain Otoscopic exam performed prior to impression No known allergy to impression material (silicone / vinyl polysiloxane)

PATIENT ACKNOWLEDGMENT & CONSENT

I understand the procedure described above and the risks involved. I have had the opportunity to ask questions about the procedure, and all of my questions have been answered to my satisfaction. I voluntarily consent to having an earmold impression taken by Eastside ENT staff. I understand that no guarantee has been made regarding the outcome of this procedure, and I release Eastside ENT and its audiologists and staff from liability for complications that may arise from thi s procedure when performed with reasonable care and in accordance with accepted clinical standards.

Patient / Guarantor Signature

Signature Date

Printed Name (if signed by representative)

Relationship to Patient

Audiologist / Staff

Witness (optional)

Date