Maternity service self-referral form

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.

<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 support network

Pregnancy and maternity history

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

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>

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:

Preferences for care

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.