| General | |
|---|---|
| 1 | I understand that Ultrasound Best (“USB”) accepts clients for fertility / pelvic scans before pregnancy and I declare that to the best of my knowledge I shall not be pregnant on the day of my appointment.……………………. |
| 2 |
I confirm that either: a – I have not experienced any vaginal since the start date of my last period, or… b – If have experienced any vaginal bleeding since the start date of my last period that I shall declare this to Ultrasound Best prior to coming for my appointment. |
| 3 | I declare that I am already engaged in an NHS or private fertility care programme. I confirm that I comply with the foregoing conditions and accept that USB might ask for proof of the same. I respect and accept the right of USB not to proceed with the scan if any of these conditions are not met. |
| Medical History | |
| 4 | I confirm that I have declared any general health conditions that I have that may have a bearing on the scan. |
| 5 | I confirm that I shall declare any fertility-related conditions that I am aware of and give any relevant associated information to the sonographer during the scan. |
| 6 | I understand that a fertility / pelvic scan will involve an internal examination using a trans-vaginal ultrasound probe. I reserve the right to decline consent at the time of the scan, but that if I exercise this right it will be fully in the knowledge that it will prevent the sonographer from getting satisfactory results. |
| 7 |
Given that the radiographer’s gloves and protective sheath for the trans-vaginal probe used for the internal examination in the fertility / pelvic 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...... |
| The Scan | |
| 8 | I understand that for best results I shall need to start the scan with a full bladder. |
| 9 | I understand that ultrasound scanning has been extensively researched and used in the NHS over the last 40 years and has been found not to cause any harm. I confirm that if at a later time scientific opinion changes I shall not USB liable for any damages. |
| 10 | I understand that the scan will be performed by a fully qualified healthcare professional registered with the Health & Care Professionals Council or Nursing & Midwifery Council. |
| 11 | 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 I do authorise him/her to declare the same to me and recommend that I contact my NHS care provider as soon as possible. I do not require the medical 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 fertility care in a medical setting, such as those providing services in the NHS institutions. |
| 12 | I understand that it is not the purpose of this fertility / pelvic scan to look for abnormalities but only to perform a visual check of the womb to enable the midwife/sonographer to make a general assessment. |
| 13 | I understand that some medical problems cannot be detected by ultrasound scans. |
| 14 | I understand USB cannot be held responsible for any abnormalities that might be found at a later date. |
| 15 | I understand that for these reasons the fertility / pelvic scan I am having is non-diagnostic and non-medical. |
| Results | |
| 16 | I shall be accompanied (“chaperoned”) during the scan by a family member or friend. |
| 17 | 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. 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 my appointment. I grant my consent and understand USB will delete all records on my request. |
| 18 |
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 serve merely as visual souvenirs of my scan.
Under no circumstances shall I use the information provided during this fertility / pelvic scan carried out by USB as a substitute for any equivalent medical scans that may performed by the NHS or private fertility specialists. |
| 19 | I confirm that I shall continue any current course of care on the NHS. |
| 20 | 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. |
| 21 | I understand that in the majority of cases it will be possible to establish with confidence the condition of my uterus but I also accept that the determination is only valid at the time of the scan. I understand that human biology is in a continuous state of development and that conditions can change rapidly, even from as little as one hour to the next. |
| 22 | I understand that the quality of the result of the ultrasound scan depends on my individual biology. I understand that good images are almost always obtained but they cannot be guaranteed. I shall hold USB harmless and not liable if it proves impossible to get a good determination of the condition of the womb during the ultrasound scan. 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. |
| 23 |
I believe that USB care sincerely for patients and want to deliver the most reliable determination of the status of my condition. I also accept, however, that sometimes client expectations cannot be met.
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. |
| 24 | I note that USB welcome feedback with regard to 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. |
| 25 | I understand that USB reserve the right to modify or improve services without giving public notice. |
| 26 | USB will provide service users with complete privacy in the examination room but advise that the reception area is a public space and that visitors 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. |
| Ultrasound Best | |
| 27 | USB will not be held responsible for any breach of this contract caused by circumstances beyond the Company’s reasonable control. |
| 28 | 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. |
| 29 | I understand that USB reserve the right to modify or improve services without giving public notice. |
| 30 | 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 a “fertility” 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