EPAU self-referral form

About you

Note: Questions marked by * are mandatory

Early Pregnancy Assessment Unit self-referral form

If you are experiencing problems in your first 16 weeks of pregnancy, please complete this Early Pregnancy Assessment Unit self-referral form.

This may be a worrying time for you and the Early Pregnancy Unit aims to support you through the early stages of your pregnancy.

If you are having heavy bleeding and/or severe abdominal pain, or feeling dizzy, please go straight to your local Emergency Department.

Completion of the form will take approximately 5 minutes. The information you provide will be placed in your medical records and only accessed by staff involved in your care. You will be contacted on the same day, or the next working day (Monday to Friday, not including bank holidays).

*This is a mandatory field. I am completing this form as a...

Patient
Other

If you selected other in the previous question, please state relationship to patient

*This is a mandatory field. In which hospital would you like to receive your care? Please note that if you do not select a preferred option we will allocate you to your nearest hospital

University Hospital Lewisham
Queen Elizabeth Hospital
I'm not sure

*This is a mandatory field. First name

*This is a mandatory field. Surname

*This is a mandatory field. Previous name(s) If no previous name please write NONE

*This is a mandatory field. Date of birth

*This is a mandatory field. Address

*This is a mandatory field. Post code

*This is a mandatory field. Contact number (you will be contacted on this number, so please ensure it is correct)

*This is a mandatory field. Email address

*This is a mandatory field. Name and address of your GP

*This is a mandatory field. Did you see your GP about this pregnancy before filling out this referral form?

Yes
No

*This is a mandatory field. Ethnicity

*This is a mandatory field. Do you need an interpreter? Please note that friends and family members are not permitted as interpreters. If you do not request an interpreter when it is required, this may result in appointments being delayed or cancelled

Yes
No

If you answered yes to the previous question, please state your spoken language

You are here: Page 1 of 2

EPAU self-referral form

Search the Lewisham and Greenwich website

EPAU self-referral form

Advice and support

CRADLE charity

Other organisations

Services submenu