Early Pregnancy Clinic self-referral | North Bristol NHS Trust

In Bristol and Weston-Super-Mare we have clinics for early pregnancy concerns, these are called Early Pregnancy Assessment Clinics (EPAC).

Where are the EPAC clinics?

Southmead Hospital EPAC, Cotswold Outpatients.
St. Michael’s Hospital EPAC, Gynaecology department.
Weston General Hospital, Ashcombe Birth Centre.

Who can go to these clinics?

At an Early Pregnancy Assessment Clinic, we provide care for people who:

Have bleeding from the vagina and/or are experiencing pain from 6 weeks to 19 weeks and 6 days of pregnancy.
Have had a past pregnancy outside the womb (ectopic pregnancy) and are now more than 6 weeks pregnant.
Have had a previous molar pregnancy.

How to come to a clinic

If you are or have experienced any of the above, you can fill out the form below to refer yourself. Your GP, midwife or emergency department doctor can also help you fill out the form.

We will call you back on the same day or the next working day (Monday to Friday) using the phone number you give us. We may talk about your symptoms or offer you an appointment.

Please read the information below before submitting the form.

Less than 6 weeks pregnant? Talk to your GP or call 111 for advice.
More than 20 weeks pregnant? Call the maternity unit at the hospital where you are booked to give birth.

If you have any of these problems, go straight to the nearest emergency department (ED) instead of completing a self-referral form:

Heavy bleeding with clots (bigger than a golf ball) that doesn't stop.
Bad abdominal pain.
Pain in your shoulder tips.
Look pale, feel dizzy, unsteady or clammy.
Severe vomiting and/or diarrhoea in early pregnancy.

Please also take a look at the following information resources:

Miscarriage: NHS website.
Miscarriage Symptoms: NHS website.
Foods to avoid in pregnancy: NHS website.
Support after a loss: Miscarriage Association.
Miscarriage information and support: Tommy's Tommys.org.
Severe sickness in pregnancy: Pregnancy Sickness Support.

Finding the right service for you

Do any of these apply to you?

Heavy bleeding with clots

Bad abdominal pain

Pain in your shoulder tips

Look pale, feel dizzy, unsteady or clammy

Severe vomiting and/or diarrhoea in early pregnancy

Go to the emergency department (ED) now. Do not fill out the form.

Do any of the following apply?

I have been treated for an early pregnancy issue within the last 8 weeks

I am under the care of the recurrent miscarriage clinic

None

Please select which hospital you were seen at

Please choose in which hospital you would like to receive your care

If you are unsure, have a look at this information page

Early Pregnancy Assessment Unit Self-Referral Form

Please fill in as much information as you can. If you need help, ask your GP. Important:

If you have heavy bleeding, bad abdominal pain, or dizziness, do not fill out this form. Seek urgent medical attention by contacting your GP, out of hours doctor service or dialling 999/ attending the accident and emergency department.
This form is only for people who are 6 weeks pregnant or more. If you are less than 6 weeks pregnant, please see your GP.
This service is not for regular pregnancy check-ups or booking your pregnancy care.

Note that these forms will be reviewed between 8am and 3pm Mondays to Fridays.
If you submit a form on a Saturday, you may not get a response until the following Monday.

Please provide your details

First name:

Last name:

Date of birth:

Address line 1

Address line 2

City/Town

Postcode

Email:

Phone number:

Do you need an translator?

Yes

Which language?

Do you have a disability?

Yes

Please tell us any accommodations or adjustments that may be needed for us to provide you the best care

Please tell us about this pregnancy

Have you had a positive pregnancy test?

Yes

Please complete a pregnancy test

If the test result is negative and you still have symptoms, please contact your GP for advice.

When was the first day of your last menstrual period?

Is this an IVF pregnancy?

Yes

Date of embryo transfer

What was the age of the embryo at transfer?

Have you had a scan in this pregnancy?

Yes

What did the scan show?

Your symptoms

Please select all that apply.

Do you have any abdominal pain?

Yes

Please describe the location and severity of the pain

Questions	No pain	Mild	Moderate	Severe
General lower abdomen	No pain	Mild	Moderate	Severe
Right lower abdomen	No pain	Mild	Moderate	Severe
Left lower abdomen	No pain	Mild	Moderate	Severe
Back pain	No pain	Mild	Moderate	Severe
Shoulder tip pain	No pain	Mild	Moderate	Severe
Other	No pain	Mild	Moderate	Severe

Do you have any vaginal bleeding?

Yes

Please describe the heaviness of the bleeding?

Spotting

Light bleeding eg on wiping

Like a period

Heavier than a period eg passing large clots

I have not had any vaginal bleeding

Have you had any of the following symptoms?

Pain or stinging when passing urine

Diarrhoea

Feeling faint or dizzy

Unusual vaginal discharge

Constipation

None of the above

Do you have any other symptoms you are concerned about?

Previous pregnancies

Please tell us about previous pregnancies

Have you been pregnant before?

Yes

How many times have you been pregnant?

If you have children how were they born?

Have you ever experienced any of the following?

Additional questions (optional)

You do not need to complete this information but it may be helpful for us to assess your symptoms

Are you currently taking any medications?

Yes

Please give details about medication

Have you ever had a previous pelvic infection ?

Yes

Please give details

Have you ever had a thrombosis?

Yes

Please give details

Do you have any medical conditions or any previous surgery?

Yes

Please give details

Did you get pregnant whilst using any of the following?

Is there anything else you would like us to know?

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