Fetal Medicine – Referral Form

First Name:	Surname:

D.O.B:	           Contact home/mob:

NHS no:					       Ethnic origin:

Address:					       GP Name:
       
						       GP Telephone:

 							

PO Number:	GP Address:
(Scotland & Wales only)

Consultant: 					       Referring Hosp:

Contact No:				

Reason for referral:
Please include previous obstetric history, screening results, relevant ultrasound findings, family history and any previously affected pregnancies and current booking blood results.

EDD:							Blood group:

														

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Office use only:

Date of referral:					Appointment Details: 

Please fax or e-mail completed form to contact details above