Ultrasound Intake

1

Are you the person who will receive the services?* This field is required.

Yes

No

2

Patients should schedule their OWN appointments. You can share our website with the patient and help them schedule, but do not submit medical information for someone other than yourself. This is to ensure safety and quality care.

3

Unique ID

4

Do you need an interpreter? If so, select the language.

5

Which language?

6

Have you had a positive pregnancy test?* This field is required.

Yes, my pregnancy test is positive.

No, my pregnancy test is negative.

No, I have not done a pregnancy test.

7

You must have a positive pregnancy test before scheduling an ultrasound appointment. An inexpensive drug store urine test works well. A doctor's office visit is not required to do a pregnancy test.

There are many things other than being pregnant that can make you miss a period. If your pregnancy test is negative, please see a primary care provider to discuss other reasons why you either missed a period or have pregnancy symptoms.

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Today's Date

Date

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It costs Aria $135 to provide you with an ultrasound. We only charge what you can afford, between $5-135. Your visit lasts about an hour.* This field is required.

I can pay $135.

I need a discount.

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We can give you a $50 discount. Your cost would be $85.* This field is required.

I can pay $85.

I can’t pay $85 — I need more of a discount.

11

What amount can you pay for your services?* This field is required.

$50

$25

$5

12

Your information is kept private. We follow all state and federal privacy laws. Aria Medical sends texts and emails for reminders.

13

What is your first name?* This field is required.

as it appears on your ID

14

What is your last name?* This field is required.

as it appears on your ID

15

Name you wished to be called

if you prefer a name other than what's on your ID

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Phone Number* This field is required.Please provide the best phone number to reach you. We will send appointment confirmations to this number. Carrier rates for SMS texts may apply. We will never share your number outside of our system or use it for marketing purposes.

Please enter a valid phone number.

17

Telehealth: Components of my visit, including interpreting the ultrasound results, may be conducted by a medical provider working remotely. I consent to receiving care through telehealth.

Ultrasound: I am scheduling an ultrasound. The purpose of this ultrasound is for pregnancy dating and to ensure the pregnancy is in my uterus. It is not for other diagnostic purposes.

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Your visit at Aria Medical Clinic usually lasts about an hour or so.

Click “Submit” below to schedule your appointment.

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Cost

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Translation services

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Date and Time