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

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. 

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

Tick here if you are **happy** for us to email you about your appointments
Tick here if you are **not happy** for us to email you about your appointments