Westminster Community Gynaecology Service GP Referral form
	
Please see inclusion /exclusion criteria before completing this form. Inappropriate referrals will be rejected.             
	
Please place an ‘X’ in the relevant box below to  indicate required service
Community clinic         OR       Triage service                                  	

	
Surname	~[Surname]	Referring GP	~[Registered Doctor]	
Forename	~[Forename] 	Practice Address

	~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Address Line 5]	
Address	~[Patient Address Block]
~[Post Code]			
DoB	~[Date Of Birth]			
Telephone 
numbers	~[Telephone Number]			
		Telephone	~[Surgery Tel No.]	
NHS number	~[NHS Number]	Fax	     	
		Referral Date	~[Today...]	
C&W Hospital Number (if known)	     	Ethnicity	     	
		Interpreter required?	Yes 	No 
Language      	
	
Clinical details / reason for referral (forms with insufficient clinical information will be returned)	
     	
Investigation results	
     	
If investigations pending, date taken (please send relevant pending results with patient if possible)	
     	
Prior treatment	
     	
CURRENT MEDICATION	
~[Medication]
     	

Referrals will only be accepted through Choose and Book. Please attach this form to the referral within 48 hours of creating the request.

If you are unable to use cab please email referral forms to:  Wms-pct.CommGynae@nhs.net 

For queries please contact the Community Gynaecology Administrator on 0203 3158381