Maternity service self-referral form

Maternity services

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Before completing this form, please ensure you meet the self-referral criteria outlined on our Refer to this service page. Unfortunately, if you do not meet the criteria, we will be unable to provide maternity care.

Please complete all fields to your best knowledge, it is important that you provide your name, date of birth, address and contact details so that we can quickly get in touch with you to talk about your pregnancy and the care.

* Required information

About you

Last name * First name * Known as Date of birth* Title Is your gender the same as your sex assigned at birth? Yes/No How would you describe your gender? How would you describe your sexual orientation? If you wish, share your pronouns (eg. she, her, he, him, they, them) Your ethnicity - please select* Mobile telephone number Aternative telephone number May we contact you by text message? Yes No Email address NHS number (if known)

You can<a href="https://www.nhs.uk/nhs-services/online-services/find-nhs-number/" target="_blank"> find information on how to obtain your NHS number here</a>

Please complete all address fields in full so that we can contact you as quickly as possible about your treatment at our London hospitals.

House number or house name * First line of address * Town/city * Country * Postcode * (e.g. W12 0HS) How long have you lived here? Are you a UK resident? Yes No

<a href="https://www.birthrights.org.uk/wp-content/uploads/2021/08/NHS-charging-FINAL.pdf" target="_blank">Read the link to understand why we ask this question.</a>

Your care preferences

Your first midwife appointment will either be at a clinic in the hospital or in a community centre. At this appointment you can discuss where you would prefer to have your pregnancy care, as well as where you would like to give birth. Our teams across both hospital sites and the community work together as one maternity service to deliver the best quality of care for you and your family. You can expect most of your midwife appointments to be held at a community centre near you.

Where do you wish to give birth to your baby? Queen Charlottes and Chelsea Hospital Du Cane Road London St Marys Hospital Paddington London Homebirth No preference Are you a refugee or asylum seeker? * Yes No Do you read and write English?* Yes No Do you require a translator or British Sign Language?* Yes No

(The NHS does not recommend use of family members to translate).

If yes, what is your preferred language?*

Let us know any dates you are unable to attend for your first appointment. Do you have any mobility, sight, hearing or other particular need that we should be aware of?* Yes No

If yes, please give details

Your support network

Emergency contact number * Next of kin name * Their relationship to you* GP's name * GP surgery address and phone number * Are you member of the Armed Forces community? Yes No

Pregnancy and maternity history

What was the date of the first day of your last period?* Is this an IVF pregnancy?* Yes No If yes, what was the date of embryo transfer? How many weeks pregnant are you now?*

If you have been receiving antenatal care in a hospital run by another NHS Trust, and you are over 30-weeks pregnant, the safest option is to remain with your current provider. If your current provider has advised you that you need to have your care in a different hospital, they will help you with that transfer.

How many babies are you expecting?* Have you had antenatal care elsewhere in this pregnancy? If yes, where? Is this the first time you have been pregnant? Yes No

Number of vaginal births: Number of caesarean births: Number of instrumental births (e.g ventouse, kiwi cup, forceps): Have you given birth to a live baby BEFORE 37 weeks? If so, how many weeks pregnant were you?

We understand the following questions may be difficult for you, but your answers will help us to provide the best care during this pregnancy:

Have you ever had a termination of pregnancy? If yes, please give details. Have you ever lost (miscarried) a baby before 12 weeks gestation? If yes, please give details Have you had any babies that were stillborn? How many weeks pregnant were you? Have you had any babies born alive, who have since died? How old were they? Did you have any medical problems in a previous pregnancy, during labour, or after the birth of your baby

(eg. gestational diabetes, high blood pressure, pre-eclampsia, itching, severe bleeding)? Please give as much detail as you can.

Your medical history

Do you or your partner have a family history of congenital disorders, learning problems or other medical genetic problems? Do you have long-term medical or mental health condition? * Yes No

If you have any of the following conditions, please specify heart condition eg birth defect high blood pressure kidney condition eg recurrent urinary tract infections stomach bowel or liver condition eg inflammatory bowel disease Crohns blood condition eg sickle cellthalassaemia blood clots endocrine condition eg Type 1 or Type 2 diabetes thyroid disease neurological condition eg epilepsy stroke mutiple sclerosis breathing difficulty eg asthma autoimmune condition eg lupus arthritis a skin condition eg eczema psoriasis cancer Mental health and wellbeing concerns? Please provide details. Anything else, not mentioned above?

Medication (prescribed or over the counter medicines):

The NHS recommends a daily dose (400mcg) of Folic Acid. Some people may need a higher dose. <a href="https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/" target="_blank">Find out more by reading the link.</a>

Are you taking medication for any medical or mental health condition? If so, please list all the medications and dosages here, including any supplements (vitamins):

Personal circumstances: we understand that these questions are sensitive. Please answer honestly so that we can arrange extra support where necessary for you and your family:

Have you (or any of your children) ever had, or still have, a social worker? If so, please give the name and telephone number of the social worker Have you ever experienced domestic violence? If yes, please give details Have you ever used recreational drugs? If so, describe what drugs you use(d) and how often. Is there anything else that you think we should know to support you during pregnancy, birth or after your baby is born?

Last updated 20 Jan 2025