Early Pregnancy Self Referral Form

Early Pregnancy Self Referral Form
Personal Information
Please complete all details
Name*
First NameLast Name
Date of Birth*
DayMonthYear
1
Address*
Street Address
Street Address Line 2
CityState / Province
Post Code
Phone Number*
Email*
example@example.com
GP Details
If unsure of address - just enter name of surgery
GP Address*
GP Name/ Surgery Name
Address Line 1
City
Post Code
Menstrual Cycle Information
Do you have regular periods?*
How long is your menstrual cycle? If unsure, please provide an approximate value
IVF Details
Please skip if not applicable
IVF / Assisted Conception?
If IVF/Assisted conception, which type?
No. of Eggs Transferred
Egg Collection Date
DayMonthYear
2
Egg Transfer Date
DayMonthYear
3
Own/ Donor Eggs?
Clinical History
Please provide as much information as possible
What are the main reasons for having this scan?
Have you experienced any bleeding during this pregnancy? If yes when did it start and is it ongoing?
Have you had any other scans in this pregnancy? If Yes, please provide details:
Have you experienced or been diagnosed with any problems 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
Please answer all questions
The 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 the following
YouYour GPYour Specialist
The 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.
Would like you to be part of The Scan Clinic Mailing List and be kept updated with all our news and promotions?
Declaration of Consent
By signing this form you are agreeing to all terms and conditions (full terms can be accessed by clicking here) without any reservation.
Please draw or write your signature below*
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Early Pregnancy Self Referral Form

Personal Information

GP Details

Menstrual Cycle Information

IVF Details

Clinical History

Data Sharing and Protection

Declaration of Consent