Use this online form to self-refer to maternity services at Queen Charlotte's & Chelsea and St Mary's hospitals. It is important to start your antenatal care early in your pregnancy, as soon as you find out you are pregnant.

Antenatal self-referral form

Completing your self-referral form

Please complete all fields on this form so that we can proceed with your booking and set up your first appointment as soon as possible.

Once we've processed your self-referral, you will be offered a face-to-face booking appointment with one of our midwives. If you have any sensitive information you wish to share before that appointment, you may contact the maternity helpline at 020 3312 6135. 

 If your form cannot be submitted due to a technical fault, please return to the antenatal referral page where you will find alternative ways to complete your self-referral. 

Antenatal referral form

Personal details

Ethnic origin
If you do not know your NHS number, please call your GP surgery for help. If you do not have a GP, please enter 'no GP' in this field.
Are you happy for us to contact you via text message about your appointment?
Do you require an interpreter?
Are you a UK resident?
GP

Current pregnancy

Where would you prefer to have your baby? Please note, you will have the opportunity to discuss this further at your first appointment.
Medication

Are you taking any current medication?
If yes, please enter details
Additional information