Referrals

We accept referrals for patients who are booked to give birth or are within one year after birth at St Mary’s Hospital or Queen Charlotte's & Chelsea Hospital.

Name Date of birth MRN / NHS number Ethnicity Asian - Any Other Asian Background Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Black - Any Other Black Background Black or Black British - African Black or Black British - Caribbean Mixed - Any Other Mixed Background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Other - Any Other Ethnic Group Other - Chinese White - Any Other White Background White - British White - Irish Prefer not to say Postcode Due date / delivery date Which hospital are you delivering / delivered at? St Marys Queen Charlottes Home birth Delivery method if applicable Vaginal Instrumental [forceps ventouse] Caesarean section 6 weeks postnatal date Reason for referral Postnatal perineal wound breakdown infection Postnatal perineal wound poorly healed Perineal scar pain Postnatal Urinary incontinence Postnatal bowel incontinence Pelvic organ prolapse Previous or current 3rd 4th degree tears Postnatal sexual pain Persistent perineal pain Difficulties that may cause issues with intimate examinations