Chelsea and Westminster Hospital
NHS Foundation Trust

ANTENATAL REFERRAL FORM
(for C&W ONLY)

T: 0208 846 7915/7916/7790
F: 0208 846 7910

Referral From: (*GP & Surgery)
«PATIENT_Registered_GP»
«PRACTICE_Name»	Address:
«PRACTICE_BlockAddress»
	
*Tel No: «PRACTICE_Main_Comm_No»  Fax No:      Email Address  	

* Please note that all fields marked * are mandatory. Failure to provide this information will delay our processing of this referral.

Patient Details
*Full Name:
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname»
*d.o.b:
«PATIENT_Date_of_Birth»
* Ethnic origin:
     	       
* Address (incl. full postcode)
«PATIENT_BlockAddress»
* Tel No: «PATIENT_Main_Comm_No»
	
*NHS No: «PATIENT_Current_NHS_Number»

* Interpreter Required?

   Yes  	No   
* Language:      	*UK Resident:     

Yes  	No  

*Date entered UK:                               
         	

*Current Pregnancy:      

*LMP:      

*EDD:      

Nuchal Scan: Discussed Yes   No 
To Be Arranged By C&W: Yes  No 

	*Prev. Pregnancies:      

Parity:      
Prev. Comments/Complications
     
Hospital No (if known):
     	

Comments (incl. medications/significant medical history)