Dose the patient being treated have any of the following conditions?

• Less than 12 years old.

• Signs of an ear infection such as fever, severe pain of the ear, or excessive redness and inflammation of the ear region.

• Allergic to over the counter medications or ingredients.

• Tympanostomy tubes in the ears.

• A ruptured tympanic membrane.

• Bleeding from the ears.

• A recent injury to the ear.

• Ear surgery within the past 6 weeks.


Yes

No






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