Early Self-Referral to Maternity Services at the L&D

Please note this form is for patients self-referring to the L&D

Once this form has been completed it will be sent to the Community Midwifery Services who will arrange your initial booking appointment with you, on the number you provide below.

If you are more than 9 weeks, please contact us as soon as you have submitted your referral form so we can process your referral and book you an appointment as soon as possible.

Please contact us if you have not heard from us within 15 working days, you can call 01582 497020, this number will get you through to maternity reception, Monday to Friday, 8am to 6pm.

Read about screening information

PLEASE DO NOT FILL IN THE FORM BELOW BEFORE READING THE SCREENING INFORMATION ABOVE.

Antenatal Self-Referral

Please complete all fields marked with an astrix (*)

By ticking this box you can confirm you have accessed the screening information link above. Please ensure you have accessed the link before continuing with this form.*

Full name*

House number and street name*

Town/city*

Postcode*

Main or preferred contact number*

Alternative contact number(s)

Date of birth*

Ethnicity

Father of baby's ethnicity

NHS number

Hospital number

GP name, surgery name and address*

Date of your last period (or due date if transferring care)*

Any previous pregnancies?*

Yes No

If yes, were any born at the L&D?*

Yes No

Are you English speaking?

Yes No

If an interpreter is required, what is your preferred language?

Do you have a disability, medical condition or any other factors we should be aware of, that may need to be considered for your antenatal care (for example - diabetes, known or history of twin pregnancy, mobility issues, sight/hearing impairment, social care involvement, mental health, etc.)?

Do you smoke?*

Yes No

Thank you for your enquiry, we will be in touch shortly.