Fertility Self Referral Form

We request that you kindly bring with you any relevant medical notes, scan results or referral forms.
Name *

First Name Last Name
Date of Birth *

Day Month Year
Our Reference
Please do not add/edit even if blank
Address Line 1 *
Town/City
Postcode *
Please enter full postcode
Phone Number *
Email *
IMPORTANT

Please do not add/edit the Appointment Date/ Time fields below, if there is an error in these fields then please contact the customer care team.
Appointment Date
Appointment Time
GP/Doctor Details

If unsure of all GP contact information please enter just name of surgery and postcode. We do not contact your GP without your permission.
GP Surgery Name *
GP Address
GP Postcode *
Menstrual Cycle Information

Please note: Baseline fertility scans are ideally performed between days 3-5 of your cycle. However your fertility/IVF clinic may require scans at other stages of your menstrual cycle. If so please kindly ask your fertility clinic to provide a referral letter/email and either bring this to your appointment or send it to our team : customercare@thescanclinic.co.uk. If you have questions about when to perform your scan please speak to your fertility care provider in the first instance.
Normally are your periods: *

Regular e.g. one period to the next is at regular intervals. Irregular e.g. one period to the next is not at regular intervals No period in the last 12 months I dont have periods
Please enter the 1st day of your most recent period (LMP) i.e. the first day you started bleeding *

Day Month Year
Number of months since last period
If this is more than 6 months then we must check this!
Approximately how long is your menstrual cycle? i.e. from start of one bleed to start of next bleed *
If unsure, please provide an approximate value
IVF Information

Please answer as much information as possible and applicable
IVF/ Assisted Conception? *
If Yes, Which type?
No.of eggs transferred
Egg collection date

Day Month Year
Egg transfer date

Day Month Year
Own/Donor eggs

Own Eggs Donor Eggs
Clinical History

Please provide as much information as possible
Reason for Scan? *

Requested by IVF Clinic / Fertility Clinic or Doctor
Have you ever been pregnant? *
Have you ever had an ectopic pregnancy? *
Do you suffer with any gynaecological problems? E.g. Polycystic ovaries, cysts *
Have you ever had a miscarriage or termination? If yes, did you have subsequent surgery or procedure performed? *
Have you ever had any form of fertility treatment? Please Specify *
Is there any possibility you could be pregnant? If unsure have you performed a pregnancy test? *
Are you currently taking any medication? If so what medications? *
Have you ever been diagnosed or treated for Cancer? *
Please provide details on any significant past medical history including any surgery: e.g. gallbladder removal, ovarian cyst removal etc. *
Data Sharing and Protection
The Scan Clinic may monitor you after specific screening tests and certain abnormal results. This allows us to check the quality of these tests to ensure that any necessary actions have taken place. Please indicate whether you’re happy for us to contact the following *

You Your NHS GP / Doctor Your Private GP / Doctor Your Fertility Clinic
The Scan Clinic offers some services which require personal data to be shared with other trusted partners for clinical purposes only and not for any commercial purpose – full details can be found by visiting our website (https://thescanclinic.co.uk/privacy). Do you give your permission for limited information to be shared. *
Would like you to be part of The Scan Clinic Mailing List and be kept updated with all our news and promotions? *
Name

First Name Last Name
Date of Birth:
Please draw or write your signature below *

Clear
Date of Signature *

Day Month Year
COVID-19 Health Declaration
For the safety of all visitors, patients, and staff it is important that we ask you the following questions and you answer honestly. If you answer YES to any of the following questions then please get in touch with our customer care team as soon as possible and DO NOT come to the clinic. we appreciate your understanding and co-operation in this matter.
Do you have or have had a high temperature? *

YES NO
Do you have a new, continuous cough (coughing for more than an hour or 3 or more coughing episodes in 24 hours)? *

YES NO
Have you been to a country or area with high risk of corona virus in the last 14 days? *

YES NO
Have been in close contact with someone with corona virus? *

YES NO
Equal Opportuniy Monitoring
We are committed to providing services that meet the needs of all members of our community. Your responses to the questions below will help us to monitor the diversity of people using our services as well as their experiences of our services and will help to inform our planning for the future. This information is anonymous and will not be used for any other purposes.
What is your age?
What is your Gender?
What is your Ethnicity?
Do you consider yourself to have a disability?

Yes No Rather not say
If Yes, please select all that apply:

Physical Impairment Sensory Impairment Learning Disability Mental Health Condition (Long Term) Other
Religion or Beliefs?
Sexual Orientation?
Declaration of Consent
By signing this form you are agreeing to all terms and conditions without any reservation, please tick the box below to confirm this and there is a link to full terms and conditions.

Please note you will have to read and scroll to the bottom of the terms and conditions before you are able to tick the acknowledgement box.
Please draw or write your signature below *

Clear
Date of Signature *

Day Month Year
Should be Empty:

GP/Doctor Details

Menstrual Cycle Information

IVF Information

Clinical History

Data Sharing and Protection

COVID-19 Health Declaration

Equal Opportuniy Monitoring

Declaration of Consent