Sonography OB Appointment Worksheet

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SONOGRAPHY OB APPOINTMENT WORKSHEET

You must be established with an OB/GYN medical provider and have had a normal diagnostic medical ultrasound prior to volunteering at Gulf Coast State College (GCSC).

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. Due to limited availability, no show/missed appointments without notification will forfeit the opportunity to schedule another appointment.

Name

Phone # with area code:

Are you at least 25 weeks pregnant?

Yes

Referred By

Date of Last Menstrual Cycle

Approximate Due Date

Doctor and Office Name

Last Dr. Appointment

Last diagnostic Ultrasound (Must have had a diagnostic ultrasound with an OB/GYN medical provider before volunteering at GCSC.)

Are you allergic to latex?

Yes

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