Referral form

Resident doctor strike

From Wednesday 17 to Monday 22 December, resident doctors (formerly known as junior doctors) will be taking strike action. During this time, our services will be under increased pressure.

Getting the right care

Please help us make sure emergency care is available for those who need it most:

Only attend A&E in life-threatening emergencies.
For non-urgent issues, please contact your GP, your local pharmacy, or NHS 111 (online or by phone).

Appointments and planned care

If your appointment is affected, we will contact you directly.
If you do not hear from us, please attend your appointment as planned.

Find out more.

Self-referral form

How do I get a referral?

You can self-refer to the EPAU by filling out our EPAU self referral form below:

Please click here to read our information guide before submitting a self-referral.

Early Pregnancy Unit - Self-referral form

Note: Questions marked by * are mandatory

Please refer to the privacy notice on how we use and store your data.

*This is a mandatory field. Please confirm that you have read the important information page before submitting this form?

Yes
No

*This is a mandatory field. Name:

*This is a mandatory field. Date of birth:

*This is a mandatory field. Age:

*This is a mandatory field. Hospital number (NHS number):

*This is a mandatory field. Address:

*This is a mandatory field. Mobile number:

Home telephone number:

*This is a mandatory field. Email address:

*This is a mandatory field. First date of last menstrual period date:

*This is a mandatory field. Date of positive pregnancy test:

*This is a mandatory field. Number of pregnancies:

*This is a mandatory field. Mode of delivery:

*This is a mandatory field. Number of previous miscarriages:

*This is a mandatory field. Number of previous ectopic pregnancies:

*This is a mandatory field. Symptoms: (Bleeding, pain, diarrhea or any other concern) Please provide as much detail as possible.

*This is a mandatory field. Number of previous scans in this pregnancy:

*This is a mandatory field. Can we leave a message via phone or email if you can't be contacted?

Yes
No

* Spam Guard: What is 2+2? (Write the number as a word.)

Referral form

Search the BHR Hospitals website

Resident doctor strike

Self-referral form

How do I get a referral?

Please click here to read our information guide before submitting a self-referral.

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King George Hospital Barley Lane Goodmayes IG3 8YB	Queen's Hospital Rom Valley Way Romford RM7 0AG
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