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

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. At both sites this includes midwifery-led birth centres and obstetric-led labour wards. We also offer care in the community, which includes home births.

If you would prefer to complete this form in another language, please scroll to the bottom right-hand side of the page and select your preferred language from the Google Translate menu. If you find it difficult to fill out this form, you can:

book an appointment with your GP instead, and they will refer you.
Call us on 020 3313 5222 and give us your details over the phone or
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 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.

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.

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 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 weeks pregnant do you think you are now?

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

How many babies are you expecting?

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 three questions above, please check with your IVF clinic.

Please remember to bring information about your IVF cycle to your appointment and first scan.

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) may be able to be looked after by a small team of midwives throughout their pregnancy, during their labour and after delivery at home, or in a midwife-led birth centre.

Are you interested in having your baby in the birth centre under the care of a small group of midwives? Yes No

Are you interested in having a homebirth? 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, postnatal depression, anxiety or other mental health issues? Yes No