Request a Consultation

ONLY COMPLETE THIS FORM IF YOU LIVE IN ONE OF THE TRUST AREAS LISTED BELOW AND ARE LESS THAN 10 WEEKS PREGNANT. If you are more than 10 weeks pregnant please see information here.

If you are less than 10 (no more than 9 weeks and 6 days from the first day of your last period) weeks pregnant and want to access early medical abortion in Northern Ireland, BPAS are taking bookings for clients on behalf of the following Trusts:

Northern Trust
Belfast Trust
South Eastern Trust
Southern Trust
Western Trust

You will receive a call for consultation within 5 working days or earlier.

Please do not complete this form unless you have a positive pregnancy test.

Personal Details

First name

Surname

Date of birth

Day

Month

Year

Email address

Phone number

Is it OK to leave a voicemail and send texts to this number?

Yes

Do you need an interpreter for your appointment?

Yes

State which language

Memorable password

Medical Questions

Date of the first day of your last period

Day

Month

Year

Your Address Details

Street

Address

Town or City

Postcode

GP Surgery Details

Your details will be used to obtain your health and care number and your basic health records, your GP will not be contacted.

GP Surgery Name

GP Surgery Postcode