Male and female sterilisation referral form

My Patient:  ~ [Title] ~[Forename] ~[Surname]
Address:  ~ [Patient Address Line 1] ~ [Patient Address Line 2] ~ [Patient Address Line 3] ~[Patient Address Line 4] ~[Patient Address Line 5]
Postcode:  ~ [Post Code] 		NHS number      			Date of Birth: ~[Date Of Birth]

Has requested:               Male sterilisation              Female sterilisation   

I am referring him / her to Marie Stopes International to make an appointment for this procedure.

Medical history 

Significant medical history:                                                                                                                

Print Name:      

Signed 			                             Date: ~ [Today...]

Please call to speak to us if there is anything is your patient’s medical history we may need to discuss

PRIVATE REFERRAL                              	           My patient is paying for this treatment

NHS REFERRAL                                                  I am referring this patient under the NHS
The CCG has an agreement to pay for the treatment

CCG Name          (if NHS referral)	

Important – Please provide GP practice / other referrer’s name, address and NHS number
Surgery Name      
~[Surgery Address Line 1] 
~[Surgery Address Line 2] 
~[Surgery Address Line 3] 
~[Surgery Address Line 4] 
~[Surgery Address Line 5] 

Tel: ~ [Surgery Tel No.]

Please check with your CCG if you are unsure about agreements

To arrange an appointment

  1. 	The referring doctor please complete the front of this form and clearly state who is funding the procedure.
Incomplete forms may result in delays in processing.

  2. 	PLEASE POST THIS FORM TO:

		Marie Stopes International Client Services , Unit 2
		Gifford Court, Fox Den Road, Stoke Gifford, Bristol, BS34 8TT
		Fax: 0845 8725 437

		If you have any queries contact our national information line:
		Tel: 0845 300 0212 local call rate (open 7 days / 24hrs) 
		Email: vasetomyservices@mariestopes.org.uk

  3. 	We will then send your patient a letter so that they can call to arrange their appointment.

Where are the Marie Stopes Centres?
				
Male sterilisation		Female 	
Ampthill	Central London	Maidstone	sterilisation	
Birmingham	Dartford	Manchester	Essex (Buckhurst Hill)	
Bristol	Ealing	Reading 		
Isle of Wight	Essex (Buckhurst Hill)	Woking		
Camberley	Leeds	Tewkesbury
Wakefield		

Services provided

The team of doctors and nurses at Marie Stopes International have over 30 years experience of providing female sterilisation and vasectomy services and have seen over 140,000 men and women for these sevices. Most people choose one visit appointments, but separate consultation and treatment appointments can be arranged. The service includes an initial consultation, procedure and all aftercare (24/7).

About Marie Stopes International

We are a specialist reproductive healthcare charity working in over 40 countries. In the UK our centres help over 100,000 patients a year privately and through our NHS agreements. Surplus funds support our vital work overseas. 

For more referral pads call 0207034 2382
 
For more information including maps and directions to our centres visit our website 

www.mariestopes.org.uk