Princess Royal University Hospital Early Pregnancy Unit ...



Princess Royal University Hospital Early Pregnancy Unit (EPU) - Referral Form:

Telephone: 01689 863571 Email: Kch-tr.pruhepagsu@

Opening Times: Monday to Friday- 09:00 to 12:30

Please note, attendance at EPU is currently by appointment ONLY. We will contact women by telephone with an appointment, AFTER receipt of completed referral form.

Please complete the form as fully as possible and send to above email address.

|Patient Details |

|Surname: |First Name: |Date of Birth: |

| | | |

|Title: | | |

|NHS Number: |Hospital Number: |Interpreter required? |

| | |Yes. Language: |

|Address |Home Telephone no: |

| |Mobile no: |

|Referral details |

|GP Name: |GP Address: |Name of referrer if not GP: |

| | | |

|Telephone: | | |

| | | |

| | |Date of referral: |

|Email: | | |

| | | |

| | | |

| | |

|Referral Indication: |Vaginal bleeding |

|(Pls tick all relevant boxes) | |

| |Abdominal pain |

|If you feel your case is particularly| |

|urgent or unusual, please contact the|2 or more previous miscarriages |

|Unit directly to discuss further AND | |

|complete this form. |High risk for ectopic pregnancy (previous ectopic; previous tubal surgery; PID; IUD in situ; pregnancy of |

| |unknown location/suspected ectopic after initial dating scan) |

| | |

| |Persistent bleeding post evacuation (medical or surgical) |

| | |

| |Clinically unstable women should NOT be referred to EPU. |

| |DATING SCANS should be booked via the Radiology Department |

|Pregnancy Status: All fields below are mandatory for an appointment in our Unit, unless otherwise stated |

| |Free text (if required): |

|Confirmed positive pregnancy test | |

|(Only women post-evacuation are exempt) | |

|LMP: ________________________ | |

|Gestation: _____________ weeks (approx.). Gestation MUST be less than 16weeks | |

|Patient has had a first trimester ultrasound confirming | |

|an intrauterine pregnancy in this pregnancy or NOT confirmed | |

| | |

|Patient known to be Rhesus negative or NOT known | |

| | |

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