Consent to Gynae Scan

I confirm that I am requesting this scan for personal reasons and that ULTRASOUND ELITE is not responsible for my primary care, and this appointment is for an ultrasound scan NOT a gynaecological consultation.

I confirm that I am the person who is having the scan and that I AM OVER 18 YEARS OF AGE (please bring valid ID as failure to do so may result in being turned away if not available at the time of scan.)

I am aware that as part of this examination a transvaginal (internal scan) maybe suggested, and will only be performed with my verbal consent.

I understand that ultrasound scan is not perfect and that not all pathologies can be detected. I understand that if the Sonographer was to detect a problem during the scan, she will inform me and direct me back into NHS care (this sometimes means discussing your case with relevant healthcare professionals).

I am aware that this appointment is for an ULTRASOUND ONLY - and is not a gynaecological consultation with a Doctor, and it is MY RESPONSIBILITY to discuss scan findings with my GP / Gynaecologist.

I will make the Sonographer aware of any underlaying medical conditions / allergies which may adversely compromise the scan (eg Latex allergies)

I am aware that routinely Ultrasound Care do not provide an independent Chaperone. I will contact them prior to scan if I wish them to arrange a chaperone.