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GP Details

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




Pregnancy Information


* 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.



Clinical History

Please provide as much information as possible




Data Sharing and Protection





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.





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.




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.


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