Patient Registration FormPatient Tools Patient Portal Registration Form Scan & Pregnancy Calculator Menstrual Cycle TrackerAppointments Upload Zone Appointment Request Patient Feedback"*" indicates required fieldsStep 1 of 616%Please complete this form before your visit to Ultrasound Care. You will need the following information available to complete this form:Medicare number and card ID (if applicable)A scanned Copy/Photo of your Request/Referral FormHave you visited Ultrasound Care or SAN Ultrasound for Women previously?* Yes NoHave any of your personal details changed since your last visit?* Yes NoPersonal DetailsFirst Name*Last Name*Do you have a Medicare Card?* Yes NoMedicare Number*Card ID*How do you describe your gender?* Woman or Female Man or Male Non-binary I use a different term (please specify) I'd prefer not to discloseWhat are your preferred pronouns?* She/her/hers He/him/his They/them/theirs I use a different term (please specify)Please specify preferred gender*Please specify preferred pronouns*Date of Birth* DD slash MM slash YYYY Work/Mobile*Email* Address*Suburb*Postcode*The location for my scan is*Please Select...AlexandriaBondi JunctionGreenwichMacquarie StreetMona ValeNewtownRandwickWahroongaPatient Consent To Release InformationPatient reports are released to the following people:Your referring doctorYour GP or SpecialistHospital Emergency Department DoctorsYour obstetric care teamMedicare (when requested and legally required)Note: Because of Medicare requirement, patient reports cannot be withheld from referring doctorsUltrasound Care and SAN Ultrasound for Women use the same Picture Archiving and Communication System (PACS). Images performed at these practices are available for review by the sonologist interpreting your study.Do you consent to your deindentified images being used for teaching, education, research,scientific communication purposes?* Yes NoDo you consent to your de-identified images being used for social media?* Yes NoDo you consent to receiving information about your appointment via SMS?* Yes NoFilms & ResultsWhen is your next doctors appointment?* Booked Already Unsure/Don't have one bookedAppointment Date* DD slash MM slash YYYY Which additional doctors or clinics would you like a copy of your report sent to?NameNameNameWill you bring any old films with you on the day of your appointment? Yes NoFurther Screening DetailsSo we can collect relevant information for your appointment please can you confirm whether you are currently pregnant?Are you currently pregnant?* Yes NoIs this your first visit to USC during this pregnancy?* Yes NoPatient Screening HistoryWeight (Kg)*Height(cm)*Is this your first ongoing pregnancy?* Yes NoPrevious Pregnancy InformationHow many times have you given birth from 24 to 27 weeks gestation?*How many times have you given birth on or after 37 weeks gestation?*Have you had any previous pregnancies that have resulted in spontaneous delivery between 16-30 weeks?* Yes NoHow many pregnancies resulted in spontaneous delivery between 16-30 weeks?*Have you had pre-eclampsia in any of your previous pregnancies?* Yes NoHave you had previously had a baby diagnosed as growth restricted?* Yes NoHave you previously had a fetus or baby diagnosed with a chromosome abnormality?* Yes NoChromosome AbnormalitiesCurrent Pregnancy InformationHave you smoked during this pregnancy?* Yes NoDo you have diabetes?* Yes NoDo you suffer from systemic lupus erythematosus (SLE)?* Yes NoDo you have high blood pressure?* Yes NoDo you suffer from antiphospholipid syndrome (APS?)* Yes NoWas your previous baby small at birth?* Yes NoDid your mother have pre-eclampsia during pregnancy?* Yes NoAre you on regular medication (other than vitamins in this pregnancy)?* Yes NoIs this an IVF pregnacy?* Yes NoEgg used in IVF Your Egg DonorIs it fresh or frozen? Fresh FrozenDate of Embryo freezing? DD slash MM slash YYYY Your Age at time of freezingDonor Age at time of freezingHave you ever had a blood transfusion, bone marrow or organ transplant?* Yes NoWhich hospital are you giving birth at?*What is the name of your Obstetrician/Clinic?*Have you had any previous ultrasounds? (If not with us, where were they performed?)Location 2Location 3Upload your request for Diagnostic ImagingAttach your referral form, previous relevant reports or any files you want to share with Ultrasound Care*Max. file size: 10 MB.File types accepted PDF, PNG, JPG, HEIC. Upload file size limit is 10mbBy clicking on ‘SUBMIT’ button below, I consent to my data being collected and stored as per Ultrasound Care’s Privacy Policy.
