Request an Appointment

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

Personal Details

First name

Surname

Date of birth day

Email address

Phone number

Is it OK to leave a voicemail on this phone number?

Yes

Do you need an interpreter for your appointment?

Yes

State which language

Memorable Password

Please choose a memorable password which we will use to check your identity. This will not be included in your confirmation email.

Medical Questions

Date of the first day of your last period

Your Address Details

Street

Address

Town or City

Postcode

GP Surgery Details

GP Surgery Name

GP Surgery Postcode

We won't contact your GP without your permission, but may need to share some personal information with other healthcare providers or organisations in order to provide your care. For example to gain NHS funding or to understand your medical history. Any person receiving your information is bound by strict data protection rules and it will only be used to help you receive the services and support you need. Read our privacy notice to find out how we use your information.

Is it OK for us to contact your GP in connection with your treatment?

Yes

Consent

We constantly monitor quality - after treatment, may we ask for your feedback by text or email?

Yes

From time to time we would like to send you news and information about our campaigns, services and ask you to take part in marketing research.

Can we contact you by:

Telephone

Text message

By submitting this request you agree that we may use your information for the purpose of booking a telephone consultation for abortion treatment. We will keep your details on our Booking and Information System and will email to notify you of the date and time of your telephone appointment.

Request an appointment for abortion services