Gynaecology Referral to CV Health
Please attach this form to the Choose and Book UBRN
Patient Details / Tel (Daytime): / «patientphone»Name: / Tel (Work):
Date of Birth: / Tel (Mobile):
Gender: / Email Address:
NHS No: / First Language:
Address: / Ethnicity:
Interpreter Required / Yes No
Tick if this patient wishes to see a female doctor
GP Details: / GP Telephone Number
GP Name: / GP Fax No:
Address: / Date of referral
Date Referral Received
Indication for Referral Checklist of Tests. Results must be sent with referral
Menorrhagia / US Scan / FBC / TFTOligo-amenorrhoea assessment / US Scan / FSH / TFT / SHBG
Prolactin / Oestradiol / Testosterone
Intermenstrual Bleeding / US Scan / HVS / ECS (Stuarts) / ECS Chlamydia
Pelvic pain / US Scan / HVS / ECS (Stuarts) / ECS Chlamydia
Vaginal discharge / HVS / ECS (Stuarts) / ECS Chlamydia
Menopausal symptoms
Minor vulval lesions
Cervical polypectomy
Fitting or removal of coil √ / For patients with primary medical need, not primary contraceptive need; we provide coils
Pessary fitting or change
Any other gynaecological conditions
Do not refer suspected cancers. If you have any queries please use Advice and Guidance.
Coils only for contraceptive needs should be referred to Bucks Sexual Health Service
Brief Clinical Details:
BMI kg/m2
Pelvic Ultra Sound Done (copy enclosed)Required (please perform)
Past Gynaecological & Medical history (please attach full hospital notes of relevant previous procedures)
Contraception: / Last smear date:
result:
Medication: «repeatmed1» «repeatmed2» «repeatmed3» «repeatmed4» «repeatmed5»
Allergies:
GP expectation from referral:
This patient has chosen the following secondary providers, should onwards referral be required:
1. BHT BMI Paddocks Chiltern Hosp Shelburne H&W Oxf Rad L&D Spire Other
2. BHT BMI Paddocks Chiltern Hosp Shelburne H&W Oxf Rad L&D Spire Other
3. BHT BMI Paddocks Chiltern Hosp Shelburne H&W Oxf Rad L&D Spire Other
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