Maternity Self-referral Form

If you would like to have your Baby with us please complete the online Self-referral form below. This applies to your first appointment for each pregnancy only.

Details around how your information is used can be found in the Your Information, your rights leaflet. If for any reason you are unable to complete the form please either print a copy or contact your GP Surgery for a paper copy.

We will not turn any women away or delay their maternity treatment even if they are not eligible for free care. Our Overseas Visitors & Liaison team will work with women to assess their eligibility and to support them and discuss payment arrangements if they are not eligible for free NHS treatment. Further information can be found in the Information for people seeking free NHS Hospital Treatment leaflet.

There is lots of information on this site about pregnancy and birth. You might want to take a look at information about screening in pregnancy and what to expect from each midwifery appointment during pregnancy before you meet your midwife.

It is recommended that all pregnant women take 400 micrograms (mcg) of folic acid each day. Ideally you should take this from before you are pregnant until you are 12 weeks pregnant. Some women, including those with a Body Mass Index over 30, or those with a medical condition such as Epilepsy, are advised to take 5 mg a day.

The Department of Health also recommends that all adults, including pregnant and breastfeeding women, need 10 micrograms (mcg) of vitamin D a day, and should take a supplement containing this amount.

PLEASE COMPLETE ALL SECTIONS OF THIS FORM

Please ensure that you make an appointment with a Community Midwife via your GP for when you are between 8 and 11 weeks pregnant after submitting the form.

If you have Type 1 or Type 2 diabetes please ring Antenatal Clinic on 01603 286795, Monday to Friday 08:30 – 17:00 where an appointment for the next clinic can be made for you, once you have completed the form.

May we contact you on this mobile number by text message?
YesNo

Have you lived in the UK for the last 12 months (required)
YesNo

Do you require an interpreter?
YesNo

Do you have a non-UK European Health Insurance card? (required)
YesNo

Please tell us about the purpose of your stay in the UK (check all that apply if applicable)
Holiday/visit friends or familyOn businessTo live here permanentlyTo workTo studyTo seek asylumOther

Have you had a scan? (required)
YesNo

Do you have any communication needs e.g. hearing loss, visual impairment or learning disability? (required)
YesNo

DECLARATION (required)
I have read & understood the reasons I have been asked to complete this form

I agree to be contacted by the Trust to confirm any details I have provided

It is my request to use email/text messaging for the purposes of my ongoing patient care within the Norfolk & Norwich NHS Trust (NNUH)

I accept that neither email or text message is a totally secure system for sending nor receiving information and that the NNUH has no responsibility for my information once it leaves an authorised NHS network at my request

The information I have given on this form is correct to the best of my knowledge

I understand that information will be shared with other relevant care providers if necessary