Termination of Pregnancy Self-Referral form

    Please note, this service is for over 18’s only. Please see your GP or Locala if you are under 18 years of age
    Please note that we are unable to arrange an appointment unless you are registered with a GP and have an NHS number.

    Fields marked with * are a mandatory requirement.

    Initial details


    What was the first day of your last period?*

    For example, 15 3 1984

    Have you performed a pregnancy test?*


    What date was your pregnancy test taken?*

    For example, 15 3 2024

    About you

    Do you give consent for us to use this number to contact you on?*

    We are unable to continue without your consent. Please ring the Self-Referral Phone Line on 01274383341 Monday - Friday 08.30 -17.00 or alternatively, see your GP or Locala


    What is your date of birth?*

    For example, 31 3 1984

    Do you need an interpreter?*

    GP Details

    Consent

    Do you give your consent for us to share this referral with your GP?*



    WHAT HAPPENS NEXT?

    Thank you NAME we have now received your referral.