Maternity self-referral form

This form is treated as confidential

Please only complete this form if you would like to receive your maternity care with BTUH.


BTUH Number (if known)
NHS Number (if known)




Your Estimated BMI:

  Date of last period is unknown

Smoking in the pregnancy/ second hand smoking is harmful to you and your baby. Our specialist midwives will send you up to date information about FREE support and treatment which will help you become smoke free

We advise you to take 400 micrograms of folic acid once a day during the first 12 weeks of your pregnancy and 10 micrograms of Vitamin D once a day throughout your pregnancy.

Once you have completed this page please click the submit button below and your referral will be passed on to one of our Maternity Direct midwives who will contact you within 5-7 working days.


I understand that by submitting this form I am confirming that I have chosen to have my maternity care with Basildon Hospital.