SELF REFERRAL FOR COMMUNITY GYNAECOLOGY

This form will enable any women living in Hull and East Riding of Yorkshire to access the Community Gynaecology Service (part of the Hull and East Riding Sexual and Reproductive Healthcare Partnership).

Please complete the form and send it to: Hull and East Riding Integrated Sexual health Service, Unit 4, Henry Boot Way, Priory Park, Hull, HU4 7DYand we will be in touch to discuss your concerns and possible treatment options. We will contact your GP after your consultation and if we need further information..

Today’s Date:______

Name:______Date of Birth:______

Address: ______Home telephone:______

______Mobile Number:______

______Email:______

Postcode: ______

GP Name and address:______

Please state why you feel you need this appointment:

  • Premenstrual Syndrome (PMS) □
  • Heavy menstrual bleeding including Mirena insertion □
  • Lost threads’ (IUD/IUS) Please send a recent pelvic scan with this request) □
  • Abnormal menstrual bleeding □
  • Pelvic pain □
  • Any other problem not listed above please state below:

______

______

Are you currently having investigations or treatment for this problem?  Yes  No

Have you had investigations or treatment for this problem in the past?  Yes  No

Do you have any disabilities? /  Yes /  No
If yes, please state:______
Do you need an interpreter? /  Yes /  No If yes, which language: ______

Past or present health problems and/or medication:______

______

Any known allergies:______

How can we contact you?

 Letter /  Mobile Telephone /  Email
 Text /  Home Telephone

Can we leave a message:

Mobile Telephone /  Yes /  No Home Telephone  Yes  No

What is the best time to contact you?(Please circle one) Morning Afternoon Evening

Can we contact you by text in the future to ask for feedback on the service?  Yes  No

WHEN CONTACTING A PATIENT WE WILL ONLY TRY 3 TIMES AND THEN THE PATIENT WILL BE DISCHARGED

TELEPHONE CALLS WILL COME FROM A WITHHELD NUMBER

U’Drive/Primary Healthcare/Sexual Health and Reproduction/Community Gynaecology/Forms/Gynaecology Self Referral Form (Sept 10)