Transcription of POSTAL REGISTRATION FORM FOR PATIENTS HAVING …
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POSTAL REGISTRATION FORM FOR PATIENTS HAVING …
POSTAL REGISTRATION FORM FOR PATIENTS HAVING HYDATIDIFORM MOLE. REGISTRATION is now ONLINE:Go to Alternatively this form may be used. Please read the supplementary notes before completing this form. Please send to one of the Centres shown on the supplementary notes. Receipt will be acknowledged. Please use the Email REGISTRATION form if you wish to email a REGISTRATION to us. 2018. REFERRING CONSULTANT PATIENT IDENTITY / AFFIX LABEL. CONSULTANT SURNAME. GMC Number FIRST NAMES. HOSPITAL No. HOSPITAL. ADDRESS NHS No. ADDRESS. POSTCODE. TEL: FAX: OBSTETRIC HISTORY. Number of live births: POSTCODE Tel: Number of pregnancies including this one: ETHNIC ORIGIN. Date of evacuation of hydatidiform mole: UNDERSTANDS ENGLISH? YES / NO / LITTLE. Date of last menstrual period prior to evac: MOTHER TONGUE/ 1st LANGUAGE? Gestational age: Uterine size: GP NAME. Classification of mole(note 4): ADDRESS.
POSTAL REGISTRATION FORM FOR PATIENTS HAVING HYDATIDIFORM MOLE Registration is now ONLINE:Go to https://nww.h-mole.nhs.uk Alternatively this form may be used. Please read the supplementary notes before completing this form.
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