Antenatal self-referral form

Completing your self-referral form

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 – Queen Charlotte’s & Chelsea and St Mary’s hospitals.

If you would like to complete this form in a language other than English, please scroll to the bottom of this page and select your chosen language from the Google translate menu. This will translate the form for you.

If you find it difficult to fill out this form, you can:

• book an appointment with your GP instead – they can refer you to us
• call us on 020 3313 5222 and give us your details over the phone
• come to the antenatal clinic at Queen Charlotte's & Chelsea Hospital or St Mary's Hospital.

Please provide as many details as possible when completing this form. This will help us ensure you get the right care as soon as possible.

We will let your GP know that you have booked your maternity care with us.

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.

 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.