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 Pregnancy Information Do you have NHS maternity notes with NHS ultrasound scan reports? Yes No * You will need to bring your NHS maternity notes with ultrasound scan reports to your appointment. Failure to do so will mean that we won’t be able to perform your scan. If you DO NOT have any NHS maternity notes or for any reason you have not had a dating or anomaly scan in the NHS then please contact our customer care team as soon as possible on 0203 904 7706 or email at by info@ultrasoundscanclinic.co.uk as we may not be able to perform a scan however our customer care team can advise further. Estimated Due Date *Is this pregnancy a result of any form of assisted conception, eg. IVF? If so can you provide details Clinical History Please provide as much information as possible What are the main reasons for having this scan? *Have you experienced or been diagnosed with any problems in this pregnancy? If Yes, please provide details: *Have you had any other scans in this pregnancy? If Yes, please provide details:Have you had any problems in your previous pregnancies? E.g. chromosomal or structural abnormality, gestational diabetes, pre-eclampsia. If Yes, please provide details: * 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 * You Your NHS GP Your Private GP / Doctor Your Specialist 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://ultrasoundscanclinic.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. Date of Signature *Submit
