Early Reassurance Scan – Consent Form

You have elected to undergo a non-clinically indicated examination involving ultrasound medical equipment. Your participation in this scan is completely voluntary.

Procedure explanation

The sonographer will use the ultrasound system to check that there is a fetal pole with a heart beat and that the fetus is correctly sited within the uterus. This scan can only be done after 7 weeks gestation.

The ultrasound scan will be performed while you are lying on an ultrasound couch and will be the same as the scan performed in the hospital. The sonographer will stop the scan if at any time there are any safety concerns.

Incidental findings

The scan will not be diagnostic and is not directed toward, nor designed for finding or diagnosing medical conditions you or the fetus may have, or develop in the future. However, on occasion, the sonographer may notice a finding on an ultrasound scan that may seem atypical. If this happens, the following procedure will be followed.

  • The sonographer will inform you that an atypical finding has been observed and give you a letter explaining the finding.

  • You can contact your GP or midwife directly to follow up on the finding.

Bump of Churchtown Ltd and the sonographers are not responsible for identifying (or failing to identify) any existing abnormalities or medical conditions you or your baby may have, or for determining whether subsequent examination or treatment is necessary of advisable, or for any subsequent examination or treatment that you decide to undergo. The collection of images is not for clinical care and the images will not be made available for diagnostic purposes.

Risks and Discomforts

There are no, known, long term or serious adverse health effects from ultrasound for the type and length of scan that you will undergo. To reduce risks we will use appropriate levels of acoustic power, within the limits recognised by authorities globally and the duration of the scans shall be kept to no more than 15 minutes for all subjects.

Ultrasound imaging is generally considered to be safe; but accidents and injury can occur.

There is always a possibility of adverse health effects from the soundwaves produced by the ultrasound system. However there are safety mechanisms built in to the equipment, and precautions will be taken by Bump of Churchtown Ltd and the sonographer to minimise the extent of these bio effects. Minor side effects resulting from the energy generated by the ultrasound device (Headaches, nausea and thermal skin heating) are extremely rare and usually resolve spontaneously.

Consent

I have read the information in this form. All my questions regarding the examination have been answered. I freely consent to undergo the examination. I have received a copy of this consent form.

I also understand that it may not be possible to see baby in a trans abdominal scan (on top of tummy) and that I will still have to pay Bump of Churchtown Ltd for their services. If this is the case one further appointment will be offered for a rescan. (Factors that can affect the scan are position of uterus, body habitus of the mother and fetus not being 7 weeks + gestation).