Waiver — Plugs by Maura

Cerumen Management & Earmold Impression Procedure.

Explanation of the Cerumen Management and Earmold Impression Procedure

Maura will….

Perform an otoscopic examination of one or both of the ears.
Determine the need for cerumen (ear wax) removal. Should removal be necessary the procedure is as follows:

A curette designed for cerumen removal will be inserted in the ear canal.
The cerumen will be scooped out of the ear canal to a designated area.
It may take several attempts to remove all of the cerumen.
Some discomfort and bleeding may occur during this procedure.
To stop the cerumen removal procedure at any time, verbally say “STOP” and Maura will stop.

3. Insert a cotton or foam ear dam (otoblock) deep into my ear using an instrument known as an otolight

4. Insert earmold impression material deep into my ear, to the dam, using a syringe designed for this purpose. The material will cure in my ears for approximately 5 minutes.

5. Remove the earmold when the impression material has solidified into a firm, rubbery consistency, and

6. Perform otoscopic examination of one or both of my ears and inform me of any redness or complication

Medical Waiver

Please fill out the form below to consent to Maura and Plugs By Maura LLC to perform cerumen removal and the earmost impression procedure

Name

First Name

Last Name

Preferred pronouns

Email

Phone

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Date

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I give permission to Plugs by Maura LLC and Maura to remove cerumen (ear wax) from my ears, as deemed appropriate.

YES

I give permission for Plugs by Maura LLC and Maura to take impressions of one or two of my ear canals.

YES

I have read the Plugs by Maura Cerumen Management and Earmold Impression Procedure Notes had the opportunity to ask questions regarding the procedure, steps, and associated materials.

YES

I understand that I can stop the procedure above at any of the steps by verbally saying: “STOP” at any time.

YES

I understand that although every aspect of the above procedures will be closely monitored for safety by Maura representing Plugs by Maura and that this is a commonly performed routine procedure, contraindications may occur in a small percentages of cases. These contraindications include possible: 1. Infection of the ear; 2. Trauma to the ear or eardrum; 3. Bruising or bleeding of the ear; 4. Allergic reaction to the impression material; or 5. Temporary hearing loss, infection, dizziness, and tinnitus 6. Earmold breakage resulting impression material lodged deep in the ear which may require removal by physician.

YES

I agree to not hold Maura or Plugs by Maura LLC liable if any of the above-mentioned symptoms occur.

YES

I agree to inform Maura of any blood thinning medications I am currently taking. (please list)

YES

Please list any blood thinning medications that you are on. If you are not on blood thinning medications, type "none"

I understand that If the skin on ear canal is sensitive and/or I am on blood thinners, I have a higher chance of experiencing bleeding.

YES

Client signature. I agree to hold harmless Maura Daniels and Plugs by Maura LLC from any injuries, damages, or claims resulting from cerumen management and earmold impression procedure performed by Maura Daniels of Plugs by Maura LLC. I am entering my name below as a form of electronic signature.

Date of Electronic Signature

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