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Ear Candling Consent Form Mobile App

Complete this detailed Ear Candling Consent Form mobile app right on your iPhone, iPad, or Android device. You can capture client information, give a brief questionnaire about the use of ear candling treatment, and reasons for today's visit such as, build-up of ear wax, ear aches, or sinus problems. You also have the ability to capture a patient's signature to document informed consent to the procedure.

All informed consent forms are stored in the GoCanvas Cloud and can be printed or emailed as a PDF. This app can be easily customized to meet your clinic's unique needs.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

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Take a peek inside the Ear Candling Consent Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip

  • Ico textbox

    Phone

  • Ico textbox

    E-mail

  • Ico dropdown

    Have you received ear candling in the past?

  • Ico textbox

    If so, what did you enjoy most and least?

  • Ico textbox

    What results are you looking for as a result of your session today?

  • Ico dropdown

    Do you wear any type of hearing air or ear tubes?

  • Ico statictext

    Check the following symptoms you have or have previously experienced

  • Ico checkbox

    Ear Aches

  • Ico checkbox

    Ear Discharge

  • Ico checkbox

    Loss of Hearing

  • Ico checkbox

    Excessive Ear Wax

  • Ico checkbox

    Swimmer's Ear

  • Ico checkbox

    Headaches

  • Ico checkbox

    Migraines

  • Ico checkbox

    Sinus Infections

  • Ico checkbox

    Allergies

  • Ico checkbox

    Sore Throats

  • Ico checkbox

    Ringing in Ears

  • Ico checkbox

    Dizziness

  • Ico textbox

    Other

  • Ico multiline

    Do you have any general health concerns that may be relevant to your session today?

  • Ico multiline

    Please list any medications you are currently taking

  • Ico textbox

    I,

  • ...and More!

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