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Service Required—Please choose an option—Dating/Viability ScanNIPT Blood testNIPT Blood Test with 10-11 week ScanFTS/NT Plus Scan & Consult12-14 week Anatomy Scan18 - 19 Week Morphology Scan20 - 21 Week Morphology ScanThird Trimester growth/wellbeingGynaecological(Pelvic) ScanFollicle Tracking within IVF CycleFollicle Tracking Not IVF2nd Opinion PelvicSonohysterogram procedureHyCoSy procedureAnatomy ScanDeep Infiltrating Endometriosis ScanTubal PatencySaline SonohysterographySaline Sonohysterography with Lipidol FlushOther - Please note under 'Comments'

Preferred Location—Please choose an option—BerwickBox HillClayton - Clayton StreetCremorneMulgraveSunshine

Preferred TimeMorningAfternoonAnytime

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Referring Doctor's Location

If Pregnancy Service:

Last Menstrual Period

Expected Date of Delivery

Single or Multiple pregnancyNot ApplicableSingleMultiple

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