Refusal of a Scan – Baby Scans 4D

Date

Client Telephone Number

Client Date of Birth

Age

Client GP Name and Address

Member of Staff Completing the Form

Please indicate the reason for refusal

Service User Signature Date

Parent or Guardian's Name (if service user is under 18)

Parent/Guardian Signature Date

Staff Signature Date

Please highlight any anticipated plan/follow up put into place.

If OTHER – please indicate

Date of Referral(s)

All staff should consider if a safeguarding referral is required

Louise Wicks Gemmell– Safeguarding Lead 07557 405 014
Corrine Tuzunlu – Deputy Lead 07718614580