Termination of Pregnancy Referral Form

Male and Female sterilisation referral form

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: Male sterilisation Female sterilisation
I am referring him/her to Marie Stopes International to make an appointment for this procedure.

Medical history

Significant medical history:
«MEDICAL_HISTORY»
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
CCG Name:
IMPORTANT: please STAMP/write GP practice/other referrer’s name and address
/ Please check withyour CCG ifyou are unsureabout agreements
Postcode:
Arranging an appointment on page 2

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

Woking

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 0207 034 2382

Visit our website for more information including maps and directions to our centres