OB/GYN ULTRASOUND at the
FAIRBANKS CLINIC
Joseph A Worrall MD RDMS
INFORMED CONSENT FOR A PRENATAL ULTRASOUND

It is estimated that 80% of pregnant women have at least one ultrasound examination during their
pregnancy. However, the "official" ruling in our Country is that ROUTINE prenatal ultrasound is not
necessary or desirable. Some European countries have laws that require ultrasound during every
pregnancy.

Because ROUTINE prenatal ultrasound is not considered the standard of care in our Country,
some third party payers will not pay for a sono without a clear clinical indication, or they will pay
for only one ultrasound during a pregnancy.

Some patients obtain their obstetrical care from sources that do not provide ultrasound except
for clinical indications. Sometimes these patients want an ultrasound and will pay for it themselves.

You will have a complete prenatal ultrasound exam even if you only want to know the gender and
get a picture. We will attempt to determine the gender if you want to know (no guarantees that
we can tell, or that we are accurate) and will make a short video or still images.

The purpose of prenatal ultrasound (depending on the duration of the pregnancy at the time of
the ultrasound) is to confirm or establish dates, determine if twins are present, look for the causes
of bleeding, evaluate the growth of the baby (if a previous ultrasound has been done so we have
something to compare to) and MOST IMPORTANTLY, TO LOOK FOR ABNORMALITIES of the fetus.

In a perfect world, (in my opinion) every pregnant woman would have two ultrasounds – one at
between 10 and 14 weeks from the last menstrual period, and another at about 20 to 22 weeks.

Prenatal ultrasound is not perfect, and we can and do miss abnormalities.

A normal prenatal ultrasound examination by no means
guarantees a normal baby at delivery.

Joseph A Worrall MD RDMS

Understanding the above, understanding that I may not know the gender of the fetus after this
exam, and understanding that not all abnormalities may be discovered, I consent to this ultrasound
examination.

My signature below also acknowledges that the Fairbanks Clinic does not provide my primary OB care. That I am requesting this ultrasound for personal, nonmedical reasons. I understand that I am responsible for payment in full prior to the ultrasound
examination.

DATE
PRINTED NAME OF PATIENT
SIGNATURE OF PATIENT
WITNESS