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Abortion - termination of pregnancy
Termination of pregnancy self ref...
Termination of pregnancy self referral form
Date of birth
Community Health Index (CHI): if known
Calls from the hospital appear as 01592 647198
We will ask for your password to confirm your identity
Preferred mode of contact
GP name and practice address
What is your first language?
Do you require an interpreter?
Do you identify with a gender different to that assigned at birth?
Date of first day of last period
If you have entered a date above, are you certain of this date?
Date of positive pregnancy test
In your current pregnancy, did you become pregnant while on contraception ie oral tablet, coil, implant etc?
If you answered yes to above, what contraception were you taking?
Have you taken any emergency contraception (for example the "morning after pill"), if yes when did you take this?
Including ill health problems you have or have had in the past e.g. diabetes, stroke, arthritis etc.
Medication you are taking
Including tablets and herbal remedies
Press submit to send referral, this will allow us to arrange an appointment to discuss your options.
Have you been pregnant before?
No. of previous pregnancies
Date of last pregnancy
Number of live births
Other pregnancy outcomes
e.g. miscarriage, ectopic, molar pregnancy
Previous Caesarean Sections
History of complications
e.g. previous haemorrhage