12-Week Pregnancy Ultrasound Appointment Checklist Form
Please complete this checklist and schedule your 12-week ultrasound appointment. This form is designed to help you prepare for your visit and ensure all necessary steps are completed.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Have you received your appointment reminder?
*
Yes
No
Checklist: Please confirm each item below is completed or ready.
Bring your referral or appointment letter
Arrive 10 minutes before your scheduled time
Drink the recommended amount of water before the scan
Bring a list of current medications (if any)
Wear comfortable, loose-fitting clothing
Do you have any questions or concerns about your appointment?
Will anyone accompany you to your appointment?
Yes
No
Preferred contact method for appointment updates
*
Please Select
Email
Phone call
Text message
Additional comments (optional)
Submit Checklist
Should be Empty: