Transvaginal Exam Consent | Harley Street Ultrasound

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Informed Patient Consent Form for Transvaginal Ultrasound

First Name *

Last Name *

Email *

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.

Do you have an allergy to latex? *

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.

I give my consent for the transvaginal examination to be performed.

I do not give consent to a transvaginal exam and understand the benefits. Still, on this occasion, I have chosen not to undertake the procedure and wish to have the opportunity to discuss it further with my practitioner.

SIGNED: | DATE: 19/12/2025

SIGNED: Harley Street Ultrasound | DATE: 19/12/2025