Audiology

Self Referral Form

 

All information is treated in strict confidentiality and will only be shared with third parties who are involved in your care.

 

Required
Required
Required
Required
Required
Required
Required
Required
Required
Required
Required

Any specific requirements, please highlight:

Required


NHS GP
 

Required
Required
Required
Required
Required
Required
Required

Patient Information


Aural microsuction is one of the safest methods used to remove wax from the ears. Side effects of ear wax removal via microsuction are rare, however, rare side effects could include; transient dizziness (lasting few seconds), minor ear bleeding, ear discomfort, ringing in the ear, ear drum perforations and hearing loss. These side effects are very rare and equate to only 1% of the total procedures performed.

We strongly advise you to use olive oil ear spray to soften the ear wax and make the procedure comfortable and tolerable. The aural microsuction charge is £75 per appointment (for one ear or both ears). In the event where no ear wax is present during the appointment, an ear health check will be performed instead which includes outer ear inspection, middle ear evaluation (tympanometry) and consultation.

Increasingly patients wish to take greater control of their own health and are becoming more aware of the opportunities to self-investigate their health issues, or simply reassure themselves that they are well.

To this end, Vista Health welcomes patients (“you”) who wish to refer themselves for Ear Microsuction. You need to be aware of and agree to the following important information prior to proceeding with a self-referral booking:

  • Aural Microsuction will only be offered to all those aged 16 and above.
  • Aural microsuction is considered to be a very safe method to remove wax from the ears. Side effects of aural microsuction are very rare. However, there has been rare known associated incidents to include: transient dizziness, minor bleeding, aural discomfort, tinnitus, otalgia and temporary hearing loss.
  • To ensure we maintain safe practice, it is mandatory for each patient to complete the digital Aural Microsuction consent form at the time of booking the appointment.
  • You must be registered with an NHS GP, to whom a copy of the report will be sent and with whom all discussions about your future care must take place. We cannot enter into any such discussions with you.
  • We cannot offer Ear Microsuction if you cannot, or do not wish to provide the name of your GP.
  • If you require further information or would like to query the content of the report, the request must be raised by a GP or medical professional.
  • You may bring a friend or relative with you, who may, if required, stay with you for the scan itself, subject to safety checks. Unfortunately, you may not bring children under the age of 16 to accompany you.
  • If you cancel your appointment with less than 48 hours’ notice charges will occur that you will have to pay.
  • Your results are available within 3 working days of the procedure and are sent to your NHS GP.
  • The NHS and private medical insurance companies will not fund or cover self-referrals. All self-referrals are undertaken on a self-pay basis only.
  • You accept that the General Patient Terms and Conditions (as provided to you in your appointment pack) apply to the services provided to you by Vista Health.
  • Please note certain sites have specific age restrictions.