Fertility Self Referral Form

GP Details

If unsure of all GP contact information please enter just name of surgery

GP Name/ Surgery Name *GP AddressGP Postcode

Menstrual Cycle Information

Please enter First Date of Last Period (LMP) *Do you have regular periods? *

• Yes
• No

Have you ever had an ectopic pregnancy? *

• Yes
• No

How long is your menstrual cycle?If unsure, please provide an approximate value

IVF Information

Please answer as much information as possible and applicable

IVF/ Assisted Conception? *

• Yes
• No

Clinical History

Please provide as much information as possible

Reason for Scan? *

• Health Review
• Unable to Conceive
• Undergoing or considering Fertility Treatment / IVF
• Requested by Fertility Clinic or Doctor
• Other

Do you suffer with any gynaecological problems? E.g. Polycystic ovaries *Have you ever had a miscarriage or termination? If yes, did you have subsequent surgery or procedure performed? *Have you ever had any form of fertility treatment? Please Specify *Is there any possibility you could be pregnant? If unsure have you performed a pregnancy test? *Are you currently taking any medication? If so what for? *Please provide details on any significant past medical history including any surgery: e.g. gallbladder removal, ovarian cyst removal etc. *How many units of alcohol do you drink in a week? *Do you smoke or use other nicotine products? If so how many per day? *

Data Sharing and Protection

Ultrasound Scan Clinic may monitor you 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 the following *

• You
• Your NHS GP / Doctor
• Your Private GP / Doctor
• Your Fertility Clinic
• Other

Ultrasound 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://thescanclinic.co.uk/privacy). Do you give your permission for limited information to be shared. *

• Yes
• No

Would like you to be part of Ultrasound Scan Clinic Mailing List and be kept updated with all our news and promotions? *

• Yes
• No

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? *

• Yes
• No

Do you have a new, continuous cough (coughing for more than an hour or 3 or more coughing episodes in 24 hours)? *

• Yes
• No

Have you been to a country or area with high risk of corona virus in the last 14 days? *

• Yes
• No

Have been in close contact with someone with corona virus? *

• Yes
• No

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?

• Yes
• No
• Rather not say

Religion 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 conditions

Please upload your signature *

Click or drag a file to this area to upload.

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