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Gynaecology services
Abortion - termination of pregnancy
Termination of pregnancy self ref...
Termination of pregnancy self referral form
Forename:
*
Surname
*
Title
Date of birth
*
Community Health Index (CHI): if known
Address
*
Postcode
*
Mobile number
*
Calls from the hospital appear as 01592 647198
Email address
*
Password
*
We will ask for your password to confirm your identity
Preferred mode of contact
*
Phone/text
Email
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?
Current pregnancy
Date of first day of last period
If you have entered a date above, are you certain of this date?
Yes
No
Date of positive pregnancy test
*
In your current pregnancy, did you become pregnant while on contraception ie oral tablet, coil, implant etc?
Yes
No
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?
Medical history
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
Allergies
*
Further information
Press submit to send referral, this will allow us to arrange an appointment to discuss your options.
Pregnancy history
Have you been pregnant before?
*
Yes
No
No. of previous pregnancies
Date of last pregnancy
Number of live births
Other pregnancy outcomes
e.g. miscarriage, ectopic, molar pregnancy
Previous Caesarean Sections
State number
History of complications
e.g. previous haemorrhage
