Sonography OB Appointment Worksheet

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SONOGRAPHY OB APPOINTMENT WORKSHEET

If you or someone who resides with you begin to show symptoms of Covid/Flu/Cold after we have scheduled your appointment, please call Ms. Tharp at 850.873.3542 or email her ctharp1@gulfcoast.edu.

If you need to cancel or reschedule, please call or email Ms. Tharp to inform her as soon as possible so that we may be able to fill in the appointment with another volunteer. Please do not NO SHOW, as it slows the students' practice hours that are needed for logged hours.

Name

Phone # with area code:

Are you at least 18 weeks pregnant?

Yes

Date of Last Menstrual Cycle

Doctor or Office Name

Last Dr. Appointment

Last Ultrasound (Must have had an ultrasound with Dr. office before coming to GCSC)

Approximate Due Date

Are you allergic to latex?

Yes

Referred By

If you or someone who resides with you begin to show symptoms of Covid/Flu/Cold after we have scheduled your appointment, please call Ms. Tharp at 850.873.3542 or email her ctharp1@gulfcoast.edu.

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