Online self-referral form for Maternity Services About you Note: Questions marked by * are mandatory Please complete this form, giving as much detail as possible so that we can ensure the best pathway for your maternity care. The information you provide will be placed in your medical records and only accessed by staff involved in your care. Please complete this form, giving as much detail as possible so that we can ensure the best pathway for your maternity care. The information you provide will be placed in your medical records and only accessed by staff involved in your care. *This is a mandatory field. I am completing this form as a... If you selected other in the previous question, please state relationship to patient *This is a mandatory field. In which hospital would you like to receive your care? Please note if you do not select a preferred option we will allocate you to your nearest hospital *This is a mandatory field. Where would you like to give birth? Please Select An Option *This is a mandatory field. First name *This is a mandatory field. Surname *This is a mandatory field. Previous name(s) If no previous name please write NONE *This is a mandatory field. Date of birth *This is a mandatory field. Address *This is a mandatory field. Post code *This is a mandatory field. Contact number *This is a mandatory field. Email address Mobile number (your appointment information will be sent to this number) NHS Number (if known) Hospital number (if known) Emergency contact details / Relationship *This is a mandatory field. Name and address of your GP Are you happy for us to contact your GP for any relevant maternity and medical history? Yes No *This is a mandatory field. Did you see your GP about this pregnancy prior to making this referral? Yes No *This is a mandatory field. Family origin of mother White British White Irish White Other Black Caribbean Black African Black Other Indian Pakistani Bangladeshi Asian Other White & Black Caribbean White & Black African White & Asian Mixed Other Chinese Any Other *This is a mandatory field. Do you need an interpreter? Please note: Friends and family members are not permitted as interpreters. If you fail to request an interpreter when it is required, this may result in appointments being delayed or cancelled Yes No If you answered yes to the previous question, please state your spoken language *This is a mandatory field. Have you been in the UK for less than a year? Yes No If you answered yes to the previous question, what was your date of arrival? DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Height (m) Weight (kg) BMI Do you smoke? If you are an ex-smoker, when did you last smoke? Does anyone in your household smoke? Yes No Proceed Summary You are here: Page 1 of 4
