First Name
*
Last Name
*
Your date of birth
*
Email Address
*
How many weeks pregnant are you today?
*
Have you had a previous scan for this pregnancy?
*
Yes
No
Where did you have the previous scan(s)?
*
Obstetrician
Hospital
Antenatal Clinic
Other imaging provider
Midwife
Name of your Obstetrician
*
Name of Hospital
*
Which antenatal clinic?
*
Which other imaging provider?
*
Name of your midwife?
*
How many weeks gestation were you at the time of your previous scan?
*
I declare that the above details are correct. I understand that if Medicare does not refund on this service then payment of this account is my responsibility. I agree that mobile phones are to be switched off before any imaging examination.
*
Patient Signature
*
Draw signature
|
Type signature
Clear
Today's date
*
Staff Use Only
Patient quoted fee $__________
Checked other imaging providers
Scanned previous reports into patient visit
Staff initials: _________ Date: ________________
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