| Pregnancy | |
|---|---|
| 1 | I understand that Ultrasound Best (“USB”) accepts clients for early pregnancy scans at no earlier than 7 weeks of gestation and I declare that to the best of my knowledge I shall be at least 7 weeks pregnant on the day of my appointment. |
| 2 | I confirm that since the start date of my last period I have not experienced any vaginal bleeding. |
| 3 | I declare that I have reported my pregnancy to my GP prior to this appointment and that I am already engaged in an NHS antenatal care programme. . |
| 4 | I confirm that I comply with the foregoing conditions and accept that Ultrasound Best (USB) might ask for proof of the same. |
| 5 | I respect and accept the right of USB not to proceed with the scan if any of these conditions are not met. |
| Medical History | |
| 6 | I confirm that I have declared any general health conditions that I have that may have bearing on the scan |
| 7 | I confirm that I shall declare any previous problems in pregnancy and give any relevant associated information to the USB administrator or health professional on arrival for the scan. |
| 8 | I confirm that I have no history of ectopic pregnancy nor any complex medical conditions. If previous history of ectopic pregnancy I confirm the NHS has declared my pregnancy as safe. |
| Transvaginal Scans | |
| 9 | I understand that owing to the early stage of gestation of the foetus the ultrasound scan may involve an internal examination using a trans-vaginal ultrasound probe and I reserve the right to give consent to the health professional to perform an internal scan upon me at the time of the examination. |
| 10 | Given that the radiographer’s gloves and protective sheath for the trans-vaginal probe used for the internal examination in the early pregnancy scan may be latex, I declare that on arrival for the appointment I shall either: - declare that I am not aware that I am allergic to latex, or…. - declare that I am allergic to latex or am unsure so that USB will use non-latex gloves/condom. |
| 11 | In the event of an internal scan, I understand that USB reserve the right to appoint a chaperone for the duration of the scan. |
| 12 | I understand that the purpose of an appointed chaperone is to ensure the safety, dignity, and respect of both myself and the sonographer is maintained. I understand that if a chaperone is refused, USB reserve the right to refuse further scanning. |
| 13 | I understand that transvaginal probes are safe and that there is no evidence use of them causes harm to pregnancy, bleeding, or miscarriage. |
| 14 | I understand that I do not incur any additional charge for consenting to the use of the transvaginal probe. |
| The Scan | |
| 15 | I understand that for best results I shall need to start the scan with a full bladder. |
| 16 |
I understand that in this early scan it will be possible only to see (i) how many babies I am carrying and (ii) if the foetus is in the right place (not ectopic); also (iii) to detect a heartbeat and (iv) to date the pregnancy - subject to a margin of error of up to a few days because of the early stage. |
| 17 | I understand any dating is approximate and subject to confirmation by an NHS dating scan |
| 18 | I understand that ultrasound scanning has been extensively researched and used in the NHS over the last 30 years and has been found not to cause any harm to mother or baby. I confirm that if at a later time scientific opinion changes, I shall not hold USB liable for any damages. |
| 19 | I understand that the scan will be performed by a fully qualified healthcare professional registered with the Society of Radiographers and Health & Care Professionals Council or Nursing & Midwifery Council. |
| 20 | I understand that for the reasons given above the healthcare professional is neither able nor authorised to offer diagnostic opinion nor medical advice in this context. If, however, the scan reveals a possible anomaly in my pregnancy I do authorise him/her to declare the same to me and recommend that I contact my NHS ante-natal care provider as soon as possible. I do not require the professional to give any information to me other than that there is a possible anomaly. I realise that confirmation of the nature of any possible anomaly can only be given by qualified and appropriately resourced medical professionals specialising in ante-natal care in a medical setting, such as those providing services in the NHS institutions. |
| 21 | I understand that it is not the purpose of this early pregnancy scan to look for abnormalities but only to perform a visual check of the foetus to enable the midwife/radiographer to make a general assessment of the status of the development of the foetus on this day during this early stage of pregnancy. |
| 22 | I understand that only a small proportion of developmental problems in foetuses can be detected using ultrasound scans, that some problems cannot be detected by ultrasound scans at all and some problems cannot be identified until the baby is born. |
| 23 | I understand that USB cannot be held responsible for any abnormalities that may be found at a later date. |
| 24 | I understand that for these reasons the foetal ultrasound scan I am having is non-diagnostic and non-medical. |
| Results | |
| 25 | USB have advised me through the USB website of my rights under the General Data Protection Regulations (GDPR) 2018, and especially as regards the Company’s privacy policy. I understand that USB do not share my information with any other entity. |
| 26 | I understand that to carry out the scan USB must capture digital files and store my personal data and medical information including images on USB IT systems up to 12 months after the birth of the baby. I grant my consent and understand USB will delete all records on my request. |
| 27 | I understand that any images from the scan reproduced as photographs are not part of my medical record and cannot to be used for medical or legal purposes but merely as visual souvenirs of my scan. |
| 28 | Under no circumstances shall I use the information provided during this early pregnancy scan carried out by USB as a substitute for the medical scans performed by the NHS as part of my ante-natal care. |
| 29 | I confirm that I shall continue my course of ante-natal care on the NHS. |
| 30 | I accept USB reserve the right to use anonymised images of my scan for education, training, research, marketing, and auditing purposes, but that my name will not be used without my prior consent. |
| 31 | I understand that in most cases it will be possible to establish with confidence the viability of pregnancy at this stage of gestation, but I also accept that the determination is only valid at the time of the scan. |
| 32 | I understand that pregnancy is in a continuous state of development and that conditions can change rapidly, even from as little as one hour to the next. |
| 33 | I understand that the quality of the result of the ultrasound scan depends on the development and location of the early-stage foetus. |
| 34 | I understand that a good image may not always be achieved. Furthermore, given that the natural biological factors of the pregnancy are beyond the control of USB and unpredictable such that they cannot be known until the scan commences, I shall hold USB at fault if it proves impossible to get a good determination of the condition of the pregnancy in the ultrasound scanning session. |
| 35 | I accept that the fee paid is for the service provided - not for souvenir pictures - and that it will be payable whatever the outcome of the scan. |
| Ultrasound Best | |
| 36 | I believe that USB care sincerely for patients and want to deliver the most reliable determination of the status of my pregnancy. I also accept, however, that sometimes client expectations cannot be met. |
| 37 | I accept that because USB professionals are qualified and experienced in the production of ultrasound images, they can advise me what is realistically achievable in the circumstances of this scan. |
| 38 | I note that USB welcome feedback about my experience and may ask me to advise during the time of the appointment if any aspect of the service is particularly appreciated or falls short of my expectations. |
| 39 | I understand that USB reserve the right to modify or improve services without giving public notice. |
| 40 | USB will provide service users with complete privacy in the examination room but advise that the reception area is a public space and that clients must take responsibility for their own valuables. The Company will accept no responsibility for any loss or damage to personal effects however caused while clients are on USB premises. |
| 41 | USB will not be held responsible for any breach of this contract caused by circumstances beyond the Company’s reasonable control. |
| 42 | I accept that payment is for a single examination, that the full fee for the service will be payable prior to the start of the scan and that it will not be refundable whatever the outcome of the scan. |
| 43 | I am aware that I must be aged 18+ by the date of my appointment in order to receive a scan from Ultrasound Best. Photo ID will be required to verify my age. Failure to provide age verification may result in my scan being refused, and the scan fee forfeited. |
I have understood and accept the above terms and conditions
I hereby freely confirm my consent to allow USB to perform an “early pregnancy” ultrasound scan on me.
This agreement shall be governed by the above terms and conditions of trade under the Law of England.
Nothing in these conditions will affect my statutory rights.
I will be required to sign a hard copy of these terms upon attending my appointment