- Maternity Direct

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)

Forename

Surname

Previous Surname (if applicable)

Date of Birth

Address

Postcode

Home Phone

Mobile Phone

Mobile Phone again

Email Address

Email Address again

GP Address

Ethnic Origin (Yours)

Ethnic Origin (Your Partner's)

Have you been resident in the UK for 12 months?

Yes

If 'No', what date did you enter the UK?

Do you require an interpreter?

Yes

If yes, what language?

Next of Kin

Relationship

Contact Number

Metric Imperial

Your Estimated BMI:

Height

ft in

Weight

st lb

Date of last period

Date of last period is unknown

Previous pregnancies

No. of Miscarriages

No. of Terminations

Existing medical conditions

Please specify medical condition information here

Previous pregnancy history

Please specify pregnancy history

Are there any smokers in the household?

Please specify other important information

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.