Princess Royal University Hospital Early Pregnancy Unit referral form
Monday to Friday, 9am to 12.30pm only
Please complete and fax to 01689 864980
NB: attendance at EPU is by appointment ONLY. We will phone all women with an appointment, AFTER receipt of
this fully completed referral form by email. Please do not advise the patient to hand deliver the form.
Patient Details (Please complete this section in full for all patients)
Surname:
First Name:
Date of Birth:
Title:
NHS Number:
Interpreter required?
Hospital Number:
Yes. Language:
Address
Home Telephone no:
Personal Mobile no:
Work Telephone no:
Referral Details: All fields below are mandatory for all patients, unless otherwise stated
Date of Referral
Form completed by:
Referring Gynaecology Consultant Team (if
applicable):
Contact no.:
Patient’s GP:
Surgery address:
GP National Practice Code:
Surgery Tel:
Surgery Fax:
Surgery email (if known):
Referral Indication:
(Please tick all relevant
boxes)
Vaginal bleeding
If you feel your case is
particularly urgent or
unusual, please contact
the EPU directly to
discuss further AND
complete this form.
2 or more previous miscarriages
Abdominal pain
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)
Please contact the Unit for advice BEFORE referral if pain or bleeding is
excessive. Clinically unstable women should NOT be referred to EPU.
NB 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
Confirmed positive pregnancy test
required):
(Only women post-evacuation are exempt)
LMP: ________________________
Gestation: _____________ weeks (approx.). Gestation MUST be less than 16 weeks
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
(Please send blood to confirm Rhesus status for ALL patients presenting to the ED at
>12weeks with vaginal bleeding and are NOT known to be Rhesus positive)
V1 December 2015, review date December 2016