Antenatal self-referral form

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.

Congratulations on your pregnancy and thank you for choosing to have your maternity care at Imperial College Healthcare NHS Trust. We provide maternity care at two hospital sites – St Mary’s Hospital and Queen Charlotte’s & Chelsea Hospital. We also offer care in the community, which includes home births.

Please provide as many details as possible when completing this form. This will help us ensure you see the right team for you as soon as possible. We will let your GP know that you have booked your maternity care with us.

Completing your self-referral form

GP's surgery name and address

Emergency contact

Name

Relationship

Phone number

Your current pregnancy

The following questions help us to understand your situation, when you will need your first scan, and what kind of maternity care you might need. Please answer as best you can. We will discuss your responses further at your first appointment.

We usually plan to see you for your first midwife appointment when you are about eight to 10 weeks pregnant. Are there any dates around this period when you are unavailable to attend? Yes No

If yes, please specify

If you are already past the 10-week mark, don’t worry. We will aim to see you within two weeks and arrange all necessary tests.

When was the first day of your last menstrual period (when your last period started)?

How many babies are you expecting?

How many weeks pregnant do you think you are now?

If you aren’t sure, your best guess is fine

Is this an IVF pregnancy? Yes No

If yes, please provide the date of your egg collection

The date of your embryo transfer?

If you had a blastocyst transfer, please specify the age of your blastocyst at transfer.

Please bring information about your IVF cycle to your appointment and first scan. If you don’t know the answers to the three questions above, please check with your IVF clinic.

Previous pregnancies

Sadly, sometimes a previous pregnancy can end in a loss. We offer bereaved parents special support in later pregnancies, as this can be a difficult and stressful time.

Have you ever given birth to a baby more than 24 weeks into the pregnancy, who died before birth? Yes No

Have you ever lost a baby shortly after birth? Yes No

Low-risk pregnancy

Women whose pregnancies are low risk (no medical problems or serious complications in previous pregnancies) are offered midwife-led care throughout their pregnancy, during their labour and after delivery.

Have you had any complications in a previous pregnancy? Yes No

If yes please give more information:

Have you ever had a Caesarean birth? Yes No

If yes, a midwife will contact you by phone to ask you more detailed questions.

Mental health

Mental health in pregnancy is just as important as physical health. We have special teams of midwives and doctors to provide support for parents with mental health difficulties.

Have you or your partner ever had depression, anxiety or other mental health issues? Yes No