Abortion services appointment request

Abortion services appointment request
(Section 1 of 4)

Please complete this checklist

Are you making this appointment request for yourself?

YesNo

Are you having severe abdominal pain or vaginal bleeding?

YesNo

Is this the first time you've contacted BPAS regarding this pregnancy including an appointment request or phone call?

YesNo

Have you done a recent pregnancy test and did it show positive within 10 mins of the result being visible?

YesNo

Are you registered with a GP?

YesNo

Do you know the date of your last menstrual period?

YesNo

Is the first day of your last menstrual period after dd/mm/yyyyy?

YesNo

Abortion services appointment request
(Section 2 of 4)

Personal Details

First name

Mandatory field

Surname

Mandatory field

Date of birth

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Mandatory field

Memorable word

Please choose a memorable word which we will use to check your identity. Please do not share your memorable word with anyone else as this is for your use only. This will not be included in your confirmation email.

Mandatory field

Contact Details

Email address

Mandatory field

Telephone number

Mandatory field

Can we leave a voicemail on this number?

YesNo

Mandatory field

Can we send text messages to this number?

YesNo

Mandatory field

Home Address

Find My Address

Country

Postcode

Please enter both country and postcode to look up address.

Something went wrong, please try again or enter the address manually.

Choose Address

Enter the address manually

Street

Mandatory field

Address

Mandatory field

Town or city

Mandatory field

Postcode

Mandatory field

Country

We are unable to accept online booking applications for Northern Ireland, please refer here

Mandatory field

Abortion services appointment request
(Section 3 of 4)

Appointment Details

If you would like to speak to a counsellor about this pregnancy before your consultation, click here. Your consultation appointment is not dependent on whether you speak to a counsellor

Do you require a language interpreter?

YesNo

Interpreter language

Interpreter dialect

Medical

GP surgery name

GP surgery postcode

Were you referred by GP?

YesNo

Height/weight measurement type

ImperialMetric

What is your height?

Feet

Inches

What is your height?

Metres

What is your weight?

Stones

Pounds

What is your weight?

KG

What is your weight?

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Accessibility

Do you have any accessibility requirements you would like us to be aware of for example easy read leaflets, large print, or any physical access needs?

YesNo

Need for an Ultrasound Scan

We are now going to ask you some questions to help us decide if you need an ultrasound scan. Please note, not all clients will require a scan. You might need a scan to date the pregnancy or to make sure the pregnancy is not growing outside of the womb (called an ectopic pregnancy). Please answer these questions as honestly and accurately as possible.

Have you had an ultrasound scan during this pregnancy and would be able to provide us with the scan report? You must be able to provide the date of the scan and gestation.

YesNo

What date was the scan carried out?

What was the gestation at the time of then scan? Weeks

What was the gestation at the time of then scan? Days

Do you know when your last menstrual period started?

Yes, I know the exact date

Yes, I know the approximate date (within 3 days either side)

What is the date your last menstrual period started?

Was your last period normal for you, in terms of amount and duration?

Yes

Don't Know/Not sure

In the 3 months before your last period, did you have regular periods about once a month?

YesNo

Have you had moderate to severe (4-or more out of 10) pain in your lower belly or pelvis in the last 48 hours?

YesNo

Have you had vaginal bleeding or spotting in last 48 hours?

YesNo

Do you have an IUD in place now or did you when you got pregnant? An IUD is a type of birth control that is placed inside your uterus by a doctor, nurse or midwife. Examples are Mirena, Jaydess, Levosert, Kyleena, and the copper coil.

YesNo

Have you ever had an ectopic pregnancy? (A pregnancy in your tube, ovary, or another place outside your uterus)

YesNo

Have you been sterilised or had any surgery on your fallopian tubes?

YesNo

Abortion services appointment request
(Section 4 of 4)

Demographics

What is your religion, if any?

What is your ethnic origin?

Do you have a disability?

YesNo

Prefer not to say

Please select at least one

Physical impairment

Mental health condition

Sensory Impairment

Long-standing illness

Learning disability/difficulty

Other

Privacy and Permissions

After treatment can we contact you about your experience?

YesNo

Please select at least one contact method

Text

Can we contact you for marketing purposes, including news and campaign information?

YesNo

Please select at least one contact method

Text

Phone

Letter

Can we contact you for research and evaluation projects of our service?

YesNo

More information about research at BPAS

Please select at least one contact method

Text

Phone

Letter

Booking Information

All clients must have a consultation. Majority of consultations are over the telephone. We have limited face to face consultations, which we cannot guarantee will be available to book. Please ensure you check your confirmation emails regarding the type of appointment you have been provided with. If you are booked a face-to-face appointment, please note we cannot support children or babies attending the appointment with you.

Your request was submitted successfully

We will process your request as soon as we can. It is important to keep checking back on your emails regularly for your appointment details.

Our opening hours are 7am to 6pm Monday to Friday, 8am to 4pm on Saturdays and 9.30 am to 2.30 pm on Sundays.

Abortion services appointment request

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Abortion services appointment request

Abortion services appointment request (Section 1 of 4)

Abortion services appointment request (Section 2 of 4)

Personal Details

Contact Details

Home Address

Abortion services appointment request (Section 3 of 4)

Appointment Details

Medical

Feet

Inches

Metres

Stones

Pounds

KG

Accessibility

Need for an Ultrasound Scan

Abortion services appointment request (Section 4 of 4)

Demographics

Privacy and Permissions

Booking Information

Your request was submitted successfully

Abortion services appointment request

Abortion services appointment request
(Section 1 of 4)

Abortion services appointment request
(Section 2 of 4)

Abortion services appointment request
(Section 3 of 4)

Abortion services appointment request
(Section 4 of 4)