Pregnancy Self-Referral Form

Congratulations on your pregnancy. If you would like to have your care at the Norfolk and Norwich University Hospital, please complete the below online self-referral form to register your pregnancy with us. Please complete this form before your first appointment.

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How is your information used?

Details about how your information is used can be found in the Your Information, your rights leaflet. Norfolk and Norwich University Hospitals NHS Foundation Trust » Your Information Your Rights poster 4.3 (

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 anyone away or delay their maternity care even if they are not eligible for free care. Our Overseas Visitors & Liaison team will work with them 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.

Screening Tests for you and your Baby

At your first appointment, your midwife will discuss the optional screening tests which are available to you during your pregnancy and after your baby is born. You may find it helpful to watch the below video  “Screening tests for you and your baby”. The video can help you understand more about what tests are offered and why which will give you the opportunity to consider your options before your midwife appointment. The video is available with subtitles in English, as well as translation options. A British Sign Language audio version is also available. View those alternatives here.



Smoking is harmful to your unborn baby. When you smoke tobacco, the toxic chemicals cross the placenta directly into the baby’s blood stream – so the baby smokes when you do. The sooner you stop smoking the better. Your GP or midwife can arrange referral for smoking cessation support.


Foods to Avoid in Pregnancy

Now you are pregnant, there are some foods you should avoid. The reason you need to avoid these foods is because some foods contain bacteria which can be harmful to your unborn baby and can even cause miscarriage.  For the most up to date list of foods to avoid, please visit the NHS website for more information Pregnancy – NHS (


Vitamins in Pregnancy

During pregnancy, it is recommended that you 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. If you have not already started, you can purchase these from your local pharmacy or supermarket. Some people, including those with a Body Mass Index over 30, or those with a medical condition such as Epilepsy, diabetes and coeliac are advised to take 5 mg a day. If you are unsure if you require a higher dose of folic acid, please ask your GP.

The Department of Health also recommends that all adults, including pregnant and breastfeeding women and birthing people, need 10 micrograms (mcg) of vitamin D a day, and should take a supplement containing this amount. Vitamin D helps to keep bones, teeth, and muscles healthy.


Vaccines In Pregnancy

During pregnancy, you will be offered some vaccinations to protect the health of you and your baby. The vaccines you will be routinely offered are the pertussis (whooping cough) vaccine, seasonal flu vaccine and covid vaccination. For more information, see the NHS Website Vaccinations in pregnancy – NHS (

What to do after the form is completed

When you have completed the form below, please call CallEast (Medicom) on 01603 481222 to book an appointment with a community Midwife. Please do this when you are between 6 – 8 weeks. If you are already more than 8 weeks pregnant, 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 diabetes clinic can be made for you to discuss your care.


Haemoglobinopathies – (Blood disorders that affect red blood cells)

A haemoglobinopathy is a genetically inherited difference in the structure or quality of haemoglobin. If you are known to be a carrier of an unusual haemoglobin (such as sickle cell, thalassaemia, haemoglobin C etc), in addition to completing the below self-referral form, please contact the Antenatal and Newborn Screening team on 01603 287949 so we can discuss screening options with you directly in addition to calling CallEast (Medicom) to book an appointment with the midwife.


Previous Pregnancies

If during your previous pregnancy or following birth, your baby was confirmed to have Downs Syndrome, Edwards Syndrome or Patau’s Syndrome (excluding partial or mosaicism) you may be eligible for a NIPT during your current pregnancy instead of the Combined/Quadruple test. In addition to completing the below self-referral form, please contact the Antenatal and Newborn Screening team on 01603 287949 so we can discuss screening options with you.


IVF Pregnancies

If you have conceived using a donor egg or embryo (not donor sperm unless a donor egg was also used) in addition to completing the below self-referral please contact the Antenatal Screening Team on 01603 287949 so we can discuss screening options with you directly.


Medical Conditions

If you are known to have HIV, Syphilis or Hepatitis B, in addition to completing the below self-referral please contact the Antenatal Screening Team on 01603 287949 so we can discuss your care with you directly.


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.

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