ULTRASOUND REQUEST. CLINICAL RADIOLOGY. UBHT.



St Michael’s Hospital, Ultrasound Department, Level E

Southwell Street, Bristol BS2 8EG

UHB NHS FT. Tel: 0117 342 5364

ULTRASOUND REQUEST for GYNAECOLOGICAL IMAGING.

Name: NHS No. Referrer: Name & Address: (Stamp)

Hospital No.

Address:

Postcode:

DoB: Practice code: L81_ _ _ _ _ _

(NB please complete)

GP SECTION: Please fill in all patient details otherwise we will be unable to accept this request.

For urgent examinations please telephone 0117 342 5347

This service is not suitable for pregnant women.

For early pregnancy problems please contact the Early Pregnancy Clinic.

|Examination: Trans-vaginal Scan |

|Clinical Details: |Previous Gynae History | |

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| |? Post Menopausal | |

| |? Medication e.g. OCP, HRT.| |

Known Inoculation Risk? Yes / No If Yes Please Specify

Drs Name: (Please Print)

Drs Signature: Date:

PATIENTS SECTION - PLEASE READ

Please telephone Monday – Friday to arrange your appointment at St Michaels Hospital

Tel 0117 342 5364 9:00 am – 12:00 noon & 2:00 pm – 5:00 pm

Please attend St Michael’s Hospital, Ultrasound Department, Level E, approx 15mins before your allotted time. Please bring this request form with you.

Please inform us if you have any special requirements e.g. wheel chair user.

Occasionally due to unforeseen circumstances you may experience a delay.

THIS IS AN INTERNAL SCAN AND YOU DO NOT NEED A FULL BLADDER

An internal scan gives excellent visualisation of the womb and ovaries, allowing diagnosis of pelvic problems. Unlike having a scan with a full bladder or some other examinations this should not be an unpleasant experience.

PLEASE ATTEND WITHIN ONE MONTH OF THE REQUEST DATE

PLEASE PRESENT WITHIN 1 MONTH

PATIENT INFORMATION

Open Access Gynae Ultrasound –St Michaels Hospital

Your GP has requested that you have an ultrasound scan, and given you a request for Open Access Ultrasound.

After seeing your GP

Please telephone the St Michaels Hospital Ultrasound Department Monday – Friday and we will endeavour to arrange your appointment at a time convenient to you. You will be asked to give your contact details.

0117 342 5364 9.00 am – 12 noon & 2:00pm – 5:00pm

Please attend approximately 15mins before your allocated time slot with your request form so that your details can be checked and request processed.

When you arrive

The waiting room serves not only the Ultrasound rooms but other departments as well, so it may appear as though some patients are being called out of turn.

We will endeavour to see you at your allotted time, however, please appreciate some examinations are more complex and may take longer than expected; your patience would be appreciated.

What does an ultrasound scan involve?

Ultrasound is the use of sound waves to produce an image. The sound waves cannot be heard but they are sent into the body and their ‘echo’ detected again after they have been reflected by the internal organs. The images are viewed on a screen.

X-rays do not generally give adequate information when imaging the soft tissue organs, whereas an ultrasound scan often shows the structure of the internal organs in good detail.

Ultrasound is regarded as a safe procedure, and is the same type of examination preformed on pregnant women during their obstetric care.

What Happens?

The examination will be performed by a Radiographer who specialises in ultrasound examinations.

YOU DO NOT NEED A FULL BLADDER AS YOU WILL BE HAVING AN INTERNAL SCAN

An internal scan gives excellent visualisation of the womb and ovaries, allowing diagnosis of pelvic problems. Unlike having a scan with a full bladder or some other examinations this should not be an unpleasant experience.

Each scan takes approximately 15 - 20 mins. On occasion an x-ray is also required to complement the ultrasound examination.

When the scan is completed you may leave immediately, and the report will be sent to your GP within 10 days, unless it is urgent when the report will be telephoned to your GP.

Any Questions? If you have any questions about the service, please contact the Ultrasound department, St Michael’s Hospital on 0117 342 5364

Any comments you have about the service will be gratefully received.

St Michael’s Hospital, Southwell Street, Bristol, BS2 8EG

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