Your GP/Doctor has requested that we perform an ultrasound to obtain
additional information. This is a diagnostic test that uses sound waves and a
computer to produce images of internal body parts. The benefit of this exam is
to assist your physician with making a diagnosis. There may be other imaging
alternatives, however, your physician believes that a sonogram to be the best
diagnostic test for you after evaluating your symptoms and medical condition at
I hereby give the Permission to perform a Transvaginal Ultrasound, a study that
requires the insertion of a probe into the vaginal canal to to further aid
the visualisation of the anatomy of the female pelvis.
This procedure is not painful but may feel uncomfortable but you can stop the
scan at any time.
1. The purpose, procedure and risks of this procedure have been explained to
2. I understand that I can terminate the procedure at any time
3. I understand that I am responsible for immediately telling the Sonographer
if I am having any discomfort and/or unusual symptoms during the procedure.
4. I hereby give the Sonographer the Permission to perform a Transvaginal
Ultrasound. I have read this consent form and understand its terms, and I am signing it knowingly and voluntarily.