Maternity Self Referral Form

Congratulations On Your Pregnancy!

Please complete the below form in order to notify us of your pregnancy. It is very important that you complete all mandatory fields (*) and that you provide us with your correct contact details. Please supply as much detail as possible when answering questions about your previous medical history or any current medication.

Self-referral Submission

Please state whether you are:

Preferred Title

If English is not your primary language do you require an interpreter?

Have you had an ultrasound scan yet this pregnancy?

Do you know if this is a twin / multiple pregnancy?

Is this an IVF pregnancy?

Are you considering or interested in our home birth service?

Have you been seen for specialist pre-pregnancy counselling or been advised to have a specialist medical review during pregnancy?

Do you have a known or suspected haemoglobin variant such as sickle cell or thalassemia?

*Have you ever been pregnant before?

*Do you have any children?

Have you ever experienced any of the following in previous pregnancies?

Do you smoke?

If yes please tick this box if you would like to be referred to the smoking cessation team to give you support and information regarding stopping smoking in pregnancy

Have you ever been under the care of a psychiatrist?

Do you currently take any regular medication?

Are you a type 1 or type 2 diabetic?

Do you suffer with any conditions affecting any of the following

Have you ever been diagnosed with any of the following

10 + 12 =

Please allow 10 working days for us to process your form, after which you should receive your appointment date. If your GP surgery does not have a midwife who works there we will also contact you to arrange a booking appointment. If you have any queries regarding your referral please contact:
Maternity referrals – asp-tr.maternityreferrals@nhs.net.

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