Fetal Cardiology Fetal Cardiology Enquiries Tel: 0117 34 25394 Email (referrals only): ubh-tr.BristolFetalCardiology@nhs.net	NHS Foundation Trust University Hospitals Bristol NHS Fetal Cardiology Department St Michael’s Hospital (Level E) Southwell Street Bristol BS2 8EG Main Switchboard : 0117 923 0000

Fetal Cardiology Referral

Please tick box to indicate if routine or urgent

Routine ☐	Urgent (48-72 hrs)☐

Date of Referral	Click here to enter a date.	Referring Hospital	Click here to enter text.
Referring Clinician	Click here to enter text.	Contact number	Click here to enter text.
Reason for Referral (As much detail as possible in accordance to the referral guidelines)	Click here to enter text.

Surname	Click here to enter text.	First Name	Click here to enter text.
NHS No ESSENTIAL	Click here to enter text.	D.O.B	Click here to enter a date.
Address	Click here to enter text.
Patient Landline:	Click here to enter text.	Patient Mob:	Click here to enter text.
EDD	Click here to enter a date.	Gestation at referral:	Click here to enter text. /40	Patient Email	Click here to enter text.

Interpreter Required? ☐ Language: Click here to enter text.	BMI Click here to enter text.	Single Pregnancy ☐ Multiple Pregnancy ☐	Gravidity: Click here to enter text. Parity:Click here to enter text.

GP Practice	Click here to enter text.	GP’s Name	Click here to enter text.
GP Address	Click here to enter text.

For Admin	Triaged by: BTG ☐ JF ☐ AH ☐ JEJ ☐ DB ☐
18 wk	Click here to enter a date.	20 wk	Click here to enter a date.	Pt Click here to enter text. No.
Comments: Click here to enter text.