Please enable JavaScript in your browser to complete this form.Full Name *Date of Birth *Our ReferencePlease do not add/edit or delete this even if blankAddress Line 1 *Town/CityPostcode *Please enter full post codePhone Number *Email *Service Booked - Please do not add/edit even if blankIf there is an error here then please contact our customer services team GP Details If unsure of all GP contact information please enter just name of surgery GP Name/ Surgery Name *GP AddressGP Postcode Referral Source Source of referral for this scan?Self-ReferralNHS GP / DoctorPrivate GP / DoctorNurseAllied Health ProfessionalOther Clinical History Please answer all questions if they apply to you and provide as much information as possibleWhat are the main reasons for having this scan(s)? *Have you experienced any of your health issues before? Please specify? *Is your GP / Doctor / Health Care Provider aware of the problem(s)? If so what actions/tests/diagnostics have been taken so far?Please provide details on any significant past medical history including any surgery *e.g. Gallbladder removal, Ovarian cyst removal, etc. or N/A if not applicableHave you ever been diagnosed with Cancer? *YesNoAre you Female (sex)?YesNo Data Sharing and Protection Ultrasound Scan Clinic may monitor certain clients after specific screening tests and certain abnormal results. This allows us to check the quality of these tests to ensure that any necessary actions have taken place. Please indicate whether you’re happy for us to contact and share your personal and necessary medical information with the following *YouYour NHS GPYour Private GP / DoctorYour SpecialistOtherUltrasound Scan Clinic offers some services which require personal data to be shared with other trusted partners for clinical purposes only and not for any commercial purpose – full details can be found by visiting our website (https://ultrasoundscanclinic.co.uk/privacy). Do you give your permission for limited information to be shared. *YesNoWould like you to be part of Ultrasound Scan Clinic Mailing List and be kept updated with all our news and promotions? *YesNo COVID-19 Health Declaration For the safety of all visitors, patients, and staff it is important that we ask you the following questions and you answer honestly. If you answer YES to any of the following questions then please get in touch with our customer care team as soon as possible and DO NOT come to the clinic. we appreciate your understanding and co-operation in this matter. Do you have or have had a high temperature? *YesNoDo you have a new, continuous cough (coughing for more than an hour or 3 or more coughing episodes in 24 hours)? *YesNoHave you been to a country or area with high risk of corona virus in the last 14 days? *YesNoHave been in close contact with someone with corona virus? *YesNo Equal Opportuniy Monitoring We are committed to providing services that meet the needs of all members of our community. Your responses to the questions below will help us to monitor the diversity of people using our services as well as their experiences of our services and will help to inform our planning for the future. This information is anonymous and will not be used for any other purposes. What is your age?What is your Gender?Click to SelectMaleFemaleN/AWhat is your Ethnicity?Click to SelectAsian or Asian BritishWhiteBlack or Black BritishOtherDropdownBangladeshiPakistaniIndianOtherBritishIrishOtherAfricanCarribeanOtherArabChineseOtherDo you consider yourself to have a disability?YesNoRather not sayReligion or Beliefs?Click to SelectAtheism Buddhism Christianity Hinduism Islam Judaism Sikhism No Religion/Belief Other Rather not say Sexual Orientation?Click to Select Heterosexual Bisexual Homosexual Other Rather not say Declaration of Consent By signing this form you are agreeing to all terms and conditions without any reservation, please tick the box below to confirm this and there is a link to full terms and conditions. I agree to terms and conditionsPlease upload your signature * Click or drag a file to this area to upload. Date of Signature *Submit
