Pregnancy Scan Informed Consent Form

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Client Details

Full Name: *

Date of Birth: *

Address: *

Postcode: *

Email Address: *

Contact Number: *

Do you have any medical conditions? *

Please list: *

Do you have any allergies? *

Please list: *

We would also like to use this information to occasionally send you news and promotional offers relevant to your pregnancy. Which channels can we contact you by? *

Phone Text Email Post No Contact

GP / Maternity Provider Information

GP / Maternity Provider Name:

GP / Maternity Provider Contact Number:

Please indicate whether or not you give consent to us contacting your healthcare provider (listed above) as necessary. *

I do consent I do not give my consent

Emergency Contact Information

Emergency Contact Name: *

Emergency Contact Number: *

Expected Due Date (EDD) / Last Menstrual Period (LMP)

Please tell us your EDD or LMP.

EDD:

LMP

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Is a scan always successful?

Factors that could cause us to not be able to obtain a satisfactory image (or sex confirmation) include:

Baby facing the wrong way
Anterior placenta
Hands and feet over baby’s face
Raised BMI
Reduced fluid around the baby
Multiple pregnancy

Please tick to confirm that you have read the above statement and understand why a satisfactory image may not be obtained. *

I understand.

Informed Consent

We want to make sure that you fully understand the ultrasound scan you have chosen. Please make sure you read this document carefully before signing this consent form at the bottom.

Please tick to confirm that you understand this scan does not replace routine diagnostic NHS ultrasound appointments. The NHS will screen for a wide range of anomalies with your pregnancy and are important to ensuring the health of both mum and baby. *

I understand.

Sex Confirmation

Do you wish to know the sex of your baby? *

Yes I wish to know the sex of my baby and understand that the determined sex at the time of the scan is not 100% guaranteed. Yes I would like to know the sex of the baby. But I would like this to be hidden from me for a surprise. I understand that the Sonographer will attempt to hide the sex as much as possible but if the sex is accidentally revealed they will not be held responsible. No I do not wish to know the sex of the baby.

Client Consent

Scan(s) to be carried out *

3D Scan 4D Scan Gender Scan

Please read and agree to the important information below:

Images can never be guaranteed, many factors which are out of our control can affect the quality of images. Our trained sonographer will attempt to provide you with the best possible imagery under the circumstances. I understand that the images from this ultrasound are mine to keep and are not for medical or legal purposes.

I understand that the scans I receive from this appointment are non medical. I accept that it is my responsibility to seek the appropriate antenatal care for my pregnancy and attend scheduled scans as recommended by my midwife, GP or Obstetrician.

I can confirm that I will declare any previous history of miscarriages, ectopic pregnancies or other information relevant to this scan.

I understand the risks in having a scan which involves the fetus. I also understand that the professional taking my scan is qualified and follows the British Medical Ultrasound Society guidelines.

Any additional notes/comments you would like to make:

I agree to the conditions and requirements laid out overleaf and confirm that these are my correct details. I agree to the above statements and I am happy for this scan to be carried out.

Client Signature: *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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