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.

Information for women who have self-referred between the 8th and 13th August

We discovered a temporary issue with our online maternity self-referral form. While the issue has now been resolved, if you submitted your form at any point from Saturday 8 August-Thursday 13 August, you’ll need to revisit the form to send this to us again or alternatively call our team on 020 3312 6135 if this is easier for you.

Please accept our sincere apologies for any inconvenience this has caused.

Completing your self-referral form

Personal details

Ethnic origin
if you are not sure of this, just enter '0000'
If you have no fixed address, please tick here
Are you happy for us to contact you via text message about your appointment?
Would you like to receive appointment letters by email instead of by post?
Do you require an interpreter/British Sign Language?
Do you have any mobility, sight, hearing or other particular needs that we should be aware of to help prepare for your appointment?
Have you already received maternity care in a different hospital or privately for this pregnancy?
Where have you lived in the last six months?
Are you a refugee or asylum seeker?
GP

Emergency contact

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?
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.
If you aren’t sure, your best guess is fine
Is this an IVF pregnancy?
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.
Your general health

Are you taking any long-term medication?
If you have any of the following conditions, please specify
Do you or your partner have a family history of learning problems, congenital disorders or other medical genetic problems?
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?
Have you ever lost a baby shortly after birth?
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?
Have you ever had a Caesarean birth?
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?
Have you ever had to take medication for any mental health issues?
Home life

We understand that these questions may be sensitive. Please answer honestly so that we can arrange extra support for you and your family.

Have you, your partner or one of your children ever had a social worker?
Have you or your partner ever been dependent on alcohol or used drugs?
Have you ever experienced domestic or any type of abuse from your partner or any member of 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.

Where would you prefer to have your baby?

Admin use only

Tick here if any of the following apply

This form is being submitted in person in the antenatal clinic
This form is being completed be a member of staff taking a telephone referral