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 a lot of information on this site about pregnancy and birth. You might find it helpful to watch the following video below for  “Screening tests for you and your baby” to learn more before you meet your midwife, as these tests will be offered at your first appointment.

There is a lot of information on this site about pregnancy and birth. You might find it helpful to watch the following video to learn more before you meet your midwife as these tests will be offered at your first appointment. The below video is also available with subtitles in English, as well as Arabic, Bengali, Chinese, French, Latvian, Lithuanian, Polish, Portuguese, Punjabi, Romanian, Somali and Urdu. A British Sign Language version is also available. View those alternatives here.

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

Following completion of this form please call 01603 481222 to book an appointment with a Community Midwife. If you are less than 6 weeks pregnant please do this when you are between 6 – 8 weeks. If you are more than 8 weeks pregnant now please do this on the next working day.

If you have Type 1 or Type 2 diabetes please ring Antenatal Clinic on 01603 286795, Monday to Friday 8:30am – 5pm 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?

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