Maternity Services self-referral form

To enable us to provide you with the best possible care for you and your baby, we ask that you please complete our maternity services self-referral form below.

For us to understand your individual needs, please answer all relevant questions giving as much detail as possible.

You will receive a telephone call from us within 5 working days of receiving your form. Please note this may be from an unknown number.

Your details

First name (required)

Last name (required)

Maiden or previous last name

Date of birth (DD/MM/YYYY) (required)

Hospital number or NHS number (if known)

Address (required)

Post code (required)

Phone (required)

Email address (required)

Which gender do you identify as? (required)

Your ethnicity (required)

Do you require an Interpreter? NoYes

Which language do you require?

Your pregnancy

What is the date of the first day of your last menstrual period?

If you are unsure of the exact date of your last menstrual period, please give the date of first positive pregnancy test. This will help us to plan your care appropriately.

The date of your first positive pregnancy test?

Your GP's details

GP name

GP surgery (required)

Your current / past medical history

Number of previous pregnancies (required)

Number of children (required)

Your first appointment

Where would you prefer your midwife antenatal care appointments to take place?

First preference (required)

Second preference? This choice must be different from your first preference (required)

There may be rare occasions when there are no clinic spaces available in your chosen area due to demand for maternity services. In this event we will book you into the midwifery clinic nearest to your given preference.

Please click the send button once. The form may take a moment to submit. A thank you message will appear if sent successfully.

For information on what we do with your data, please see our privacy notice.

Your maternity notes will be available on the Airmid app and we will register you for access at your first contact phone call. You may wish to download the app via Google Play store or Apple App Store.

If you have not heard from us within 14 days of submitting this form, please call 01803 656588.