Termination of pregnancy referral form by MJJKZn

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									NHS Camden Termination of pregnancy referral form
Please give this form to your patient and ensure they bring it to their appointment
 My patient:       «PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname»

 Address:      «PATIENT_House» «PATIENT_Road», «PATIENT_Locality», «PATIENT_Town»



 Postcode:         «PATIENT_Postcode»                       Date of birth:    «PATIENT_Date_of_Birth»
 Patient NHS number: «PATIENT_Current_NHS_Number»
 has requested help with her unplanned pregnancy. I have advised her to contact
 Marie Stopes International to make an appointment.


Medical history
 Pregnancy test:       Home       GP       FPC       Chemist        LMP:                Gestation:

 Significant medical history:
 «MEDICAL_HISTORY»




 There are no aspects of my patient’s history which cause me to have reservations about daycare treatment.
    I ATTACH A SIGNED HSA 1

 Your role: Referring GP                Signed: «REFERRAL_Clinician»              Date: «SYSTEM_Date»



 Private referral                                               My patient is paying for this treatment



 NHS referral                                                    I am referring this patient under the NHS

 The Primary Care Trust has an agreement to pay for the treatment

 PCT Name: Camden
 IMPORTANT: please STAMP/write GP practice/other referrer’s name and address


                                                                                               Please check
                                                                                               with your PCT
                                                                                               if you are
                                                                                               unsure about
                                                                                               agreements

 Postcode:
                                                                             Arranging an appointment on page 2
Central Booking:                                                          Providers:
                                                                          Marie Stopes International

0845 300 2922 (open 7 days / 24 hrs)                                      Royal Free Hospital
Local call rate                                                           EGA University College Hospital (UCH)


  To arrange an appointment
  Telephone our national information and appointments line.
  They will arrange your appointment and give you all the details you need. Please ask us any questions you may have.



Bring this form to your appointment and any other information your doctor has given you


What will happen at my appointment?
When you call the Marie Stopes Central Booking line, they will be able to explain your options. You will be offered a
choice of:

Counselling: if you feel you need to talk to someone and are not quite sure what to do, we can arrange an appointment
for you to see one of our experienced counsellors.

Initial consultation and medical assessment: everyone will see a doctor or nurse to assess their pregnancy, establish
grounds for their abortion under the 1967 Abortion Act and explain the treatment options.

Up to 14 weeks gestation we are able to offer an initial consultation and abortion all on the same day or as
separate appointments if you wish.

Over 14 weeks gestation you will have to attend two visits – consultation first, then the abortion appointment.



  Abortion treatment choices
  These are the different choices of treatment at different gestations:

  Medical abortion                                  Surgical abortion
  Two visits required for treatment                 One visit only appointments available
  Up to 9 weeks gestation                           Up to 12 weeks gestation with local anaesthetic
                                                    conscious sedation and general anaesthetic
                                                    12-19 weeks gestation with conscious sedation
                                                    or general anaesthetic
                                                    19-24 weeks gestation with general anaesthetic



Main centres
Central London Essex (Buckhurst Hill)       South London (Brixton)    Bristol    Leeds    Manchester   Maidstone   Reading
West London (Ealing)

Regional pregnancy advice centres
Blackpool    Canterbury   Preston     Woking



www.mariestopes.org.uk

								
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