Maternity Services self-referral form

Please fill in our maternity self-referral form.

This helps us give you and your baby the best care possible.

It is best to fill in the form when you are about 6 weeks pregnant.

Please answer all the questions that apply to you. Give as much information as you can so we can understand your needs.

We will call you within 5 working days after receiving your form. Please note that the call may come from an unknown or withheld 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 (you can find this on the NHS app)

Address (required)

Postcode (required)

Phone (required)

Is it okay for us to leave you a voicemail message? NoYes

Email address (required)

Which gender do you identify as? (required)

Your ethnicity (required)

Do you require an Interpreter? NoYes

Which language and dialect do you require?

Do you smoke, or have you smoked in the last 2 weeks? NoYes

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?

Emergency contact details

This can be a partner, family member or friend.

First name (required)

Last name (required)

Do they live at the same address? If yes, leave blank.

Address

Postcode

Phone (required)

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

Your GP's details

GP name

GP surgery (required)

Your past pregnancy 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.

Other information

Is there any other information that you feel is important for us to know about you at this stage?

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 your MY CARE record. MY CARE is really easy to use on your smartphone or tablet by downloading the MyChart app.

Download on the App Store Get it on Google Play

Before hearing from us, you may like to look on the NHS website for pregnancy information.

If you have not heard from us within 14 days of submitting this form, please call 01803 655771 or call freephone 08081 756947.