To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Please select your option
At least 72 hours
A week
A month
More than a month

If yes, what medicine was consumed and how effective was it?

Please select your option
Male
Female

Please select your option
Presently Pregnant
Presently Breastfeeding
Planning on getting pregnant
Planning on Becoming Pregnant
Neither Pregnant nor Breastfeeding

Please provide more information of the medication being used if any.

You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function


You can select more than one option
Itching
In the ear canal there is pain or discomfort
An ear canal discharge that is watery
The skin surrounding the exterior of the ear and around the canal is dry and flaking
Due to swelling and inflammation the ear canal becomes obstructed
Hearing impairment



Ear infections that last a long time.
Ear infections caused by fungi.
Wax in your ears that needs to be removed with drops or ear syringing

You've had cholesteatoma (an abnormal growth of skin in the middle ear beneath the eardrum) from birth or as a result of repeated ear infections.
You've experienced ear difficulties in the past that necessitated a visit to an ear, nose, and throat specialist.
You have facial nerve palsy and suffer pain in your jaw when chewing or speaking (drooping face on the side of the lesion)
You have a fever of more than 39°C, you are physically ill, and you have vertigo.
You suffer from severe hearing loss.
You have an infection that has migrated beyond your ear.
You have a large amount of ear discharge.

A grommet was installed.
An eardrum that has been perforated (tympanic membrane)
Dysfunction of the kidneys or the liver


A healthcare practitioner should assess any acute injuries.
You should see your doctor about chronic pain at least once a year.

Please provide more information

If not, please describe in detail who the intended consumer is and how old he/she is.





If yes, please describe the product and the reaction



If yes, please provide details


If yes, please provide details





Please list all your current prescription medication including any medication you buy over the counter.




Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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- You declare that I have answered the above truthfully- You will read the patient information leaflet before taking your medication (if prescribed)- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor