Ear Candling Consultation and Consent Form | Beauty Forms Portal

Ear Candling Consultation/Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Do you have any of the following? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Have you previously tried Ear Candling? *

What are your reasons for having Ear Candling? *

Do you have any hearing problems or pain in your ears? *

Have you consulted a medical professional regarding the problem? *

Treatment Information

Ear candling is a holistic and complementary treatment - it is therefore not designed to treat/cure any particular ailment. It is a natural approach and many people say they find it helpful for maintaining general health and well-being.

Those who may benefit from ear candling include those struggling with:

migraines
hay fever
anxiety and stress
post flying and driving pressure
swimmer’s ear
asthma
vertigo
yeast infections
colds and flu
parasites
itching in the ears

Ensure you speak to your doctor about your symptoms to see if medical assistance is required. Ear candling works well as a complementary treatment, alongside medical interventions.

The treatment involves one end of the Ear Candle being placed into the ear while the other end is lit, creating a mild chimney effect which gently and naturally encourages any unwanted residues to make its way out of the ear in it's own time. Please note that the candles do not "suck" anything out of your ear canal as is sometimes suggested and there is a filter in the narrow end that is placed into the ear to ensure that nothing falls into the ear itself.

Candling can aid stress relief in general and may also reduce the discomfort experienced from certain conditions. The treatment is first and foremost intended for relaxation so if you have any ear problems or problems with your hearing then you should visit your doctor or an audiologist.

While it is considered a natural approach with no side-effects, ear candling does carry risks. Having a lit candle inserted into the ear requires expert handling and supervision to avoid potential problems such as a punctured eardrum or burns to the face, hair, scalp or ear.

Generally, ear candling is a safe and relaxing experience - as long as the treatment is not used excessively or carried out incorrectly.

Aftercare Advice

After Your Treatment

After receiving an Ear Candling treatment it is perfectly normal to experience the following, known as contra-actions:

Cold like symptoms
Sticky feeling within the ears or the losing of ear wax
Headache or Slight dizziness
Slight dryness in the throat

These reactions will last no longer than 24-48 hours, but if you have any concerns please feel free to contact us.
You may also experience:

Improvement in clarity of sound
Lighter feeling in the head and face due to sinus pressure relief

Aftercare

Ear wax/residue may naturally work its way out of the ear over the following 24-48 hours, this is normal (We recommend that you protect your pillows with a towel to prevent staining of your bedding).
Do not submerge your head under water for 24 hours after your treatment and try to avoid cold air blowing into your ears.
Do not insert anything, including cotton buds inside your ears.
Drinking plenty of water, squash, or herbal teas to help eliminate toxins and flush out the lymphatic system.
If you experience a runny nose please blow it gently rather than sniffing.
If you had a bit of a cold at the time of your treatment please note your symptoms may get worse.
You should leave a minimum of 48 hours between treatments.

Follow up treatment depends on the nature of the ear complaint, please speak with your therapist for additional advice.

Please tick the box to confirm: *

I have read and understood the aftercare advice given to me.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive Ear Candling Therapy.

Client Signature: *

Tap or click on the signature above to sign