Self Referral Form

Please complete all relevant details as soon as possible following your positive pregnancy test so we can book you in for your first appointment in a timely manner. Any missing information may slow this process. You will normally be seen for your first appointment at 8–10 weeks, depending on your gestation when we receive your self-referral. If you haven’t been contacted within 10 working days, please call the Community Liaison Office on 01142 268301.

Please fill out this form in English.

* is a required field.

Required Fields

Please fill in the required fields.

1. Who is completing this form? *

Self
Professional/3rd party (please give details)
Details:

2. Personal details

First name *

Surname *

Date of birth

Maiden name (if applicable)

Marital status *

Single
Married
Civil partnered
Divorced
Widowed

Preferred contact number *

Can we send text/sms messages to this number to notify you of appointments? *

Yes
No

Email address *

Can we email you at this address? *
Yes
No

Hospital number (if known) NHS number (if known) Ethnicity *

If Other - any other ethnic group, please enter your ethnic group name

Your ethnicity describes your cultural or ancestral heritage, which is inherited from your ancestors, your parents or grandparents. This may be different to your nationality, which is your legal identity, the country where you are a legal citizen. You may have been born in this country, or you may have moved here and became a citizen. Knowing your correct ethnicity is important to us as it helps us provide the best possible maternity care for you as an individual. Pregnant people from certain ethnic backgrounds can be more at risk of some pregnancy complications.

Do you require an interpreter? *
Yes
No

Our Trust policy excludes the use of friends or relatives as interpreters. If we do not know about your interpreter requirements in advance, we may need to reschedule your appointment.

If yes, which language do you speak?

Let us know any dates you cannot attend your booking appointment

Let us know the details of any disability we need to be aware of when arranging your appointment

Where have you lived in the last 12 months? *
Within the UK
Outside the UK
(please bring your passport or any other documentation you have to support your residency in the UK)

3. Your address *

Street address 1 *

Street address 2

Town *

County

Postcode *

4. Next of kin *

Name of next of kin *

Relationship to you *

Contact number *

Can we contact them in an emergency regarding your pregnancy if required? *
Yes
No

5. GP details

GP/practice name *

Street address 1

Street address 2

Town

County

Postcode

Contact number

6. Current pregnancy

First day of your last period
(if unsure, please leave blank and answer the next question)

Approximately how many weeks pregnant are you? *
If you have had antenatal care elsewhere for this pregnancy, please provide details (name of hospital and country)

Total number of pregnancies *
(including miscarriages or terminations)

Number of vaginal births *

Number of assisted births (Kiwi/ventouse/forceps) *

Number of Caesarean sections *

Number of pre-term births (before 37 weeks) *

Number of babies born <3rd centile *

Details of any babies diagnosed with a medical condition before or after birth

Any other details
(for example assisted fertility, pre-eclampsia, obstetric cholestasis, gestational diabetes etc)

7. Medical history

Medical and mental health history *:

Cardiac (heart) condition
High blood pressure
Sickle cell/thalassaemia (or carry the trait)
Diabetes
Renal (kidney) disease
Liver disease
Haematology (blood) condition
Thyroid disease
Neurological (brain) condition
Respiratory condition (eg asthma)
Cancer treatment
I am a smoker
Someone in my house smokes
Mental health problem (eg depression, anxiety, eating disorder etc)
None of these

(please tick all that apply)

If you ticked any of the above, please provide brief details including any medication taken

8. Social complexities *

Please tick all that apply

No recourse to public funds
Learning difficulties
Social worker
Safeguarding concerns
Alcohol use concerns
Domestic abuse concerns
Substance use concerns
None of these

If you ticked any of the above, please provide brief details

9. Vaccination

Have you been vaccinated for COVID-19?
Yes - 1 dose
Yes - 2 doses
Yes - 2 doses + booster
No

Studies have shown that hospital admission and severe illness are more common in pregnant women (compared to those not pregnant).

Form submission

You can use the Previous and Next buttons to review each page of the form before submitting.

If all your details are correct then please Submit the form below.