Prolonged Jaundice Pathway Request

Please complete the below form to place a child on the prolonged jaundice pathway.

An email will be sent to the patient’s parent/guardian explaining what the prolonged jaundice clinic is and requesting the parent to submit an image of a stool sample.

    Patient Details






    Format as RGQ000000



    Patient Assessment



    in weeks. e.g. 37+4

    Only if all of the below tick boxes are satisfactory can the baby come to clinic. Otherwise, the baby must be seen on PAU/PIU. Please call the paediatric SPR on bleep 544.


    NormalPaleUnknown











    Please enter any other information that may be useful

    Please explain that it is very important that their baby is seen at the next available slot, even if this is not quite as convenient as an appointment a week later. This is because we screen for the rare causes of prolonged jaundice and in some situations, it is better to make the diagnosis as soon as possible.

    The hospital monitors the availability of clinic slots carefully, but if you are referring late or there are no slots available within 2 weeks, please discuss with the paediatric SPR via 01473 712233, bleep 544, who will be able to help find a suitable time for the child to be seen.

    Available Slots
    Fri 25 Jun14:0014:2014:4015:0015:20
    Mon 28 Jun14:0014:2014:4015:0015:20
    Fri 02 Jul14:0014:2014:4015:0015:20
    Mon 05 Jul14:0014:2014:4015:0015:20
    Fri 09 Jul14:0014:2014:4015:0015:20



    Please explain to the parents they will receive an email asking them to share a photo of their child’s dirty nappies prior to their appointment.

    Please ensure that they have received the email with the appointment details, which is generated by clicking the button below.