EPAU self-referral form

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Note: Questions marked by * are mandatory

Early Pregnancy Assessment Unit self-referral form

If you are experiencing problems in your first 16 weeks of pregnancy, please complete this Early Pregnancy Assessment Unit self-referral form.

This may be a worrying time for you and the Early Pregnancy Unit aims to support you through the early stages of your pregnancy.

If you are having heavy bleeding and/or severe abdominal pain, or feeling dizzy, please go straight to your local Emergency Department.

Completion of the form will take approximately 5 minutes. The information you provide will be placed in your medical records and only accessed by staff involved in your care. You will be contacted on the same day, or the next working day (Monday to Friday, not including bank holidays).

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