Ear Cleaning

This package includes one or two visits. On the first visit, Dr Rienstra will examine you to be sure that you have no other condition than excessive earwax and that it is safe to clean your ears. (If not, there is no charge.) Then our nurse will remove your earwax. Sometimes a second visit is necessary if wax is particularly hard, as it is painful to remove in that condition.

How it works

We clean your ear using a water jet, so don't wear your best clothes. We will use a drape to keep the water from your shirt or blouse, but sometimes you may become a bit damp.

Insurance Billing

We cannot give a refund once your insurance has been billed. Once treatment is complete and you are satisfied, we will provide you with a health insurance claim form. You can complete this and send it to your insurance company. (We do not provide billing forms for anyone on Medicare, Washington Basic Health, or similar insurance.)

Requirements

- You must be over 18 years of age (or at least sixteen years old if living independently.)

- You can not be suffering from an infection of the ear canal.

- Other than tubes in the ears that are now removed, you must have no history of ear surgery.

Agreement

I request ear-cleaning. To my knowledge I do not have a hole in my eardrum. In such a case, irritation of the middle ear could result, with possible damage to my hearing.

I understand side effects of treatment may be:
- Temporary dizziness.

- Temporary irritation of ear canal.

Note: Any procedure on the ear, including cleaning with a cotton swab or any cleaning procedure in a physician's office can rarely result in perforation of the eardrum.

I agree that payment will be refunded only if these conditions have been met.

· I return for repeat treatments as scheduled by the clinic.

· That my earwax is not removed.

I understand Dr Rienstra may determine by his examination that I have some problem more complex than simple earwax accumulation. In that case,

_____ I wish to terminate the No Cure - No Pay procedure with no diagnosis given.

_____ I wish Dr Rienstra to give me his diagnosis and treatment and will pay the usual office fee.



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Print name                                                        Date

3/27/04