Assoc. Prof. Rob Cincotta
MBBS FRANZCOG
DDU CMFM

Dr. Jackie Chua
MBBS FRANZCOG
DDU COGU

Dr. Carol Portmann
MBBS MSc FRANZCOG
CMFM

TO MAKE AN
APPOINTMENT

Brisbane
Ph: 07 3831 1777
Fax: 07 3831 1788
brisbane@qufw.com.au

Southport
Ph: 07 5528 2934
Fax: 07 5528 3849
southport@qufw.com.au

Tugun
Ph: 07 5610 4973
Fax: 07 5604 1192
tugun@qufw.com.au

Ipswich
Ph: 07 3447 9111
Fax: 07 3492 9299
ipswich@qufw.com.au

Toowoomba
Ph: 07 4542 7855
Fax: 07 4602 0145
toowoomba@qufw.com.au

	PATIENT DETAILS	

Name:	
<PtFullName>	

Date of Birth:	
<PtDoB>	
Contact Phone:	
<PtPhoneMob>	

Address:	
<PtStreet> <PtCity> <PtPostcode> <PtState>	

LMP:	
<LMP:>	
EDC:	
<EDC:>	

OBSTETRIC REQUEST <OBSTETRIC REQUEST>	
<Singleton Pregnancy> Singleton Pregnancy	
<Multiple Pregnancy> Multiple Pregnancy	

<Early Pregnancy Assessment> Early Pregnancy Assessment	
<Morphology (20-22 weeks)> Morphology (20-22 weeks)	
<Growth Scan> Growth Scan	

<NIPT (includes viability scan)> NIPT (includes viability scan)	
<Cervical Assessment> Cervical Assessment	
<AFI and Doppler only> AFI and Doppler only	

<First Trimester Screening/Early Anatomy (includes PET screening)> First Trimester Screening/Early Anatomy (includes PET screening)	
<CVS / Amniocentesis> CVS / Amniocentesis	

Other: 	
<OBSTETRIC REQUEST: Other (please specify):>	

GYNAECOLOGY REQUEST <GYNAECOLOGY REQUEST>	

<Gynaecology Scan> Gynaecology
Scan	
<Endometriosis Assessment> Endometriosis
Assessment	
<Follicle Tracking> Follicle
Tracking	
<HyFoSy (Tubal Patency)> HyFoSy
(Tubal Patency)	
<Saline Infusion Sonography> Saline Infusion
Sonography	

Other:	
<GYNAECOLOGY REQUEST: Other (please specify):>	

CLINICAL DETAILS <CLINICAL DETAILS>	

<Enter clinical detail here:>	

REFERRED BY	

Name:	
<DrName>	
Provider #:	
<DrProviderNo>	

Signature:	
	
Date:	
<TodaysDate>	

	
PREPARATION
A Patient Form link will have been sent to you electronically. Please complete and submit this form well before your appointment time. Please bring your referral from your doctor. If you had previous scans and reports done elsewhere, please let us know who you had the scans with so we can obtain your reports electronically. Empty your bladder one hour before your appointment and then drink 400 mls of water. Please refrain from emptying your bladder before your appointment. If you are feeling uncomfortable please inform the front reception staff.

OBSTETRIC ULTRASOUND EXAMINATION
Obstetric scans are generally performed on your abdomen. In early pregnancy and for other medical imaging reasons, a transvaginal ultrasound scan maybe necessary.	GYNAECOLOGICAL ULTRASOUND EXAMINATION
Transabdominal and transvaginal examinations are usually required for adequate assessment. If you have any concerns, feel free to discuss them with your sonographer.

DURATION
QUFW is a tertiary-level private ultrasound group and sometimes, delays may occur due to managing patients with high risk complex medical conditions. Most examinations will take 45-60 minutes, however please allow around 90 minutes for your visit to accommodate for any delays.
Please refer to our website for our current visitor restrictions and children policy.	

LOCATIONS AND PARKING	

Level 1, Leichhardt Court
55 Little Edward Street,
Spring Hill, Qld 4000

Brisbane Parking
Metered street parking on Little Edward and Boundary Streets (Please be aware of clearway zone at certain times of the day). Parking underneath the Leichhardt Court building (orange section) with entry via Hope Street. Online bookings are recommended through Wilson parking.			
	Suite 8B, Level 8, Fred McKay House
42 Inland Drive, Tugun, Qld 4224

Tugun Parking
Free and paid parking available on hospital grounds.
	Level 4, 7 Short Street
Southport, Qld 4215

Southport Parking
4 hour metered street parking on Short Street. Additional parking is available in the Gold Coast council Carey Park carpark or Australia Fair Shopping centre.

	Suite 5B, 10 Churchill Street,
Ipswich, Qld 4305

Ipswich Parking
Up to 2 hours free parking behind the building and on street paid parking available.	Suite 201a, Medici Medical Centre, 
15 Scott Street, Toowoomba, Qld 4350

Toowoomba Parking
Limited street parking is available. Paid parking available on 
Level B1 via Scott Street.