Ultrasound Questionnaire

Ultrasound Scan Questionnaire

Please complete this questionnaire before booking your private ultrasound scan.

Ultrasound does not use ionising radiation. Some urgent symptoms still need medical assessment before imaging.

Patient details

First name * Last name * Date of birth * Gender * Email * Phone number *

Ultrasound details

Reason for ultrasound * How long has this been present? * Have you had previous imaging for this issue? *

Urgent symptom checks

Do you have severe abdominal pain? * Do you have fever or feel acutely unwell? * Do you have jaundice or yellowing of the eyes or skin? * Is this related to pregnancy or possible pregnancy? *

Declaration

I confirm that the information I have provided is accurate.

I understand that my scan request may still be reviewed before the appointment is confirmed.

I consent to being contacted about this scan request.