King’s College Hospital Early Pregnancy Unit referral
Mon – Fri, 9am – 12pm
Please complete and email this form to kch-tr.KCHReferrals@nhs.net or hand it
to the patient to bring with them
The visit will include an ultrasound scan and other investigations where clinically
indicated. Please note: this is not a referral for routine antenatal care.
Patient details
Name
Date of Birth
NHS number
Address
Telephone
GP
Reason for
referral
(please
circle)
Vaginal bleeding
Reassurance (not
appropriate before 7/40)
Abdominal or pelvic pain
Dating
Clinical details & suspected diagnosis:
V4, November 2015, review date November 2017
High risk of ectopic
pregnancy (previous
ectopic / pelvic adhesions)
Ovarian cyst in pregnancy