Custom Fitting Procedure Client Consent
I have elected to be custom fit with dB Blocker hearing protection.
PROCEDURE INFORMATION
I understand that a Communication Health Assistant (CHA) who is not a health care provider, and under the general supervision of a CHCPBC Audiology Registrant, will perform the ear impression procedure to obtain custom molded hearing protection. The procedure involves:
- Visual inspection of the ear with a pen light
- Placement of a foam/cotton block to protect the eardrum
- Filling the ear with silicone-based impression material for ~5 minutes
- Removal of the hardened mold and block
- Final visual inspection to ensure no material remains
RISKS AND CONTRAINDICATIONS
I understand that there are risks associated with ear impressions, including:
- Pushing existing wax deeper into the ear canal
- Irritation or tearing of the ear canal wall or ear drum
- Impact on existing conditions or previous surgical procedures
- Worsening of certain conditions like Meniere's Disease or skin conditions
The procedure cannot proceed if there is:
- Visible foreign body or impacted wax in the ear canal
- Presence of fresh blood
- Pathological/skin conditions of the ear, canal, or drum
- Signs of infection in the outer ear or ear canal
- Perforated ear drum
MEDICAL HISTORY
Please check all that apply:
- I have a history of ear surgery. If yes, please explain: __________
- I have known outer/middle ear conditions. If yes, please explain: __________
- I have a communicable disease that can be transferred by touch or bodily fluids. If yes, please explain: __________
- I am taking blood thinning medication (Coumadin, Heparin, high-dose Aspirin)
CONSENT STATEMENTS
By signing below, I confirm that:
- I am fully informed of each step of the ear impression procedure and the associated outcomes, benefits, and risks
- I understand the nature of the treatment, expected benefits, potential risks and side effects, alternative options, and consequences of not having the treatment
- I will disclose and agree to the CHA disclosing if the impression becomes contaminated with blood, body fluids, or discharge to the supervising RAUD and manufacturing facility
- I understand that in case of emergency, the CHA will contact the supervising Audiologist and appropriate medical facility
- I understand that I can ask the CHA to reach out to the supervising RAUD on my behalf at my request
- I consent to proceed with the ear impression procedure
- I understand I may cancel or rescind my consent at any time in writing
