Patient Information

You have been referred or have self-referred for a Pelvic Ultrasound which may require a Transvaginal Ultrasound. You must understand the procedures that are associated with this examination.

• The ultrasound transducer will be placed in the vagina (the probe is sterilised).
• The transducer will be introduced with a latex / non-latex type covering.

• Moving the transducer from side to side, up and down, and swivelled to obtain clear images will be necessary.
• A third person may be present during the examination acting as a chaperone if required by the Doctor or yourself.
• You may request the examination be stopped at any time during the examination.

Patient Consent

• I acknowledge that the examining doctor/clinician has explained the proposed procedure.
• I have been provided with information regarding the proposed procedure.
• I understand the risks and complications involved in the procedure.
• I understand the right to change my mind at any time, including after I have signed this form but preferably the following discussion with my doctor.
• I have been provided with the opportunity to have any questions answered.

OR

SIGNED: |DATE: 10/09/2025

SIGNED: Harley Street Ultrasound  | DATE: 10/09/2025