Male and Female Sterilisation Referral Form

Male and female sterilisation referral form

My Patient:

Name / NHS No.
Address / Date of Birth
Home Telephone
Work Telephone
Email / Mobile Telephone

Has requested: Male sterilisation Female sterilisation Not funded by ENHCCG - for private patients only

I am referring them to Marie Stopes International to make an appointment for this procedure.

Medical history

Reason for Referral:

Significant medical history:

Print Name:

Signed: ______Date:

My Details:

GP Practice / Telephone
Address / Fax

Please call to speak to us if there is anything is your patient’s medical history we may need to discuss

PRIVATE REFERRAL Patient is paying for this treatment

NHS REFERRAL I am referring this patient under the NHS

The CCG has an agreement to pay for the treatment
CCG Name: East & North Herts CCG (if NHS referral)

Important – Please provide GP practice / other referrer’s name, address and NHS number

Registered GP: GP/Clinician
Surgery Name
Tel:

Please check with your CCG if you are unsure about agreements

To arrange an appointment

1.The referring doctor please complete the front of this form and clearly state who is funding the procedure.

Incomplete forms may result in delays in processing.

2.PLEASE POST THIS FORM TO:

Marie Stopes International Client Services, Unit 2

Gifford Court, Fox Den Road, Stoke Gifford, Bristol, BS34 8TT

Fax: 0845 8725 437

If you have any queries contact our national information line:

Tel: 0845 300 0212 local call rate (open 7 days / 24hrs)

Email:

3.We will then send your patient a letter so that they can call to arrange their appointment.

Where are the Marie Stopes Centres?

Male sterilisation / Female
Ampthill / Central London / Maidstone / sterilisation
Birmingham / Dartford / Manchester / Essex (Buckhurst Hill)
Bristol / Ealing / Reading
Isle of Wight / Essex (Buckhurst Hill) / Woking
Camberley / Leeds / Tewkesbury
Wakefield

Services provided

The team of doctors and nurses at Marie Stopes International have over 30 years’ experience of providing female sterilisation and vasectomy services and have seen over 140,000 men and women for these services. Most people choose one visit appointments, but separate consultation and treatment appointments can be arranged. The service includes an initial consultation, procedure and all aftercare (24/7).

About Marie Stopes International

We are a specialist reproductive healthcare charity working in over 40 countries. In the UK our centres help over 100,000 patients a year privately and through our NHS agreements. Surplus funds support our vital work overseas.

For more referral pads call 0207034 2382

For more information including maps and directions to our centres visit our website