Ear Impressions Consent

"*" indicates required fields

Name*

First Last

Date of Birth*

Must be 16 years and older

Have you ever had ear surgery?*

Yes

No

Are you on any blood thinning medication?*

Yes

No

Do you have a history of ear infections?*

Yes

No

How long since your last ear infection?*

Less than a month

1-6 months

Over 6 Months

Not since I was a kid

Informed Consent*

I have been fully informed of each step of the ear impression procedure and the outcomes, benefits and risks associated with the process.

Which product are you ordering?*

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