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
? 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
Issued March 2012
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
Issued March 2012