Pregnancy self-referral details

Red heat-health alert

Very high temperatures are expected this week, so we’re asking everyone to take a little extra care if you’re visiting one of our hospitals.

Our teams are working hard to keep services running safely.

Please take a few simple steps to stay safe and comfortable:

If you’re unable to attend, please let us know as soon as possible. Find out more on how to manage your appointment.

Thank you for your patience and understanding as we work to keep our patients, visitors and staff safe during the hot weather.

Your details

Note: Questions marked by * are mandatory

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

Title

*This is a mandatory field. First name

*This is a mandatory field. Surname or family name

Previous name (if any)

*This is a mandatory field. Date of birth

*This is a mandatory field. Address

*This is a mandatory field. Postcode

Enter your NHS number (if known)

Enter your Hospital Number (if known)

*This is a mandatory field. Can we contact you via email?

Yes
No

If yes, what is your email address?

*This is a mandatory field. Contact number (mobile or landline)

*This is a mandatory field. Can we call you on this number?

Yes
No

*This is a mandatory field. Do you require an interpreter? (please note: family members or partners cannot be used as interpreters)

If yes, preferred language?

Sight problems?

Yes
No

Hearing loss?

Yes, completely
To some extent
No

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

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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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