Maternity services – Self-referral form
The Royal Free London NHS Foundation Trust has full maternity services at the Royal Free Hospital in Hampstead, Barnet General Hospital in Barnet and at North Middlesex University Hospital (North Mid). We also provide antenatal care at Chase Farm Hospital in Enfield. We have a stand-alone birth centre in Edgware Hospital in Edgware. We would happily facilitate a home birth for you. We also provide care from GP surgeries and other satellite units.

Congratulations on your pregnancy! We are delighted to welcome you to our Trust. It would really help us in planning your care if you could fill out as much of the below referral form as possible please. Any information you provide will be treated in the strictest of confidence.

Personal Information

Surname: *
First name: *
Date of Birth: *
Your Address: *
Postcode: *
Your NHS number (if known):
Mobile number: *
Can we text you on this number? *
Other contact number:
Email: *
Are you happy for us to send letters and e-mails to your contact details? *
GP practice/surgery: *
Address: *
Post code:
GP Tel Number:
What language do you speak: *
Do you need an interpreter? *
Do you have sensory or communication needs we should be aware of?
How would you describe your Family Origin: *
AFRICAN OR AFRICAN CARIBBEAN


SOUTH ASIAN


SOUTH EAST ASIAN


NORTHERN EUROPEAN (White)
OTHER NON – EUROPEAN


SOUTHERN AND OTHER EUROPEAN (White)


UK (White)


Have you lived in the UK for longer than 6 months? *

How far along in your pregnancy are you?

What was the first day of your last period (LMP)?
If you are unsure please tick here
How many weeks pregnant do you think you are?
Is this pregnancy IVF?
If yes, when was the embryo transfer date?
About Your Pregnancy/Pregnancies
Is this your first pregnancy?
How many vaginal deliveries have you had?
This includes if you needed help from a Doctor using
Have you had a Caesarean section, if yes how many?

Caesarean Section
Have you suffered a pregnancy loss between 14 to 24 weeks?
Do you have a history of 3 or more miscarriages?
Have you had a previous Stillbirth or Fetal Abnormality?
Have any of your babies passed away in the first 12 months of life?
Your Health
CONDITION
Have you had a previous admission to High Dependency Unit (HDU) or Intensive care unit (ITU)?
Are you diabetic?   
Do you have a neurological(brain) condition, such as epilepsy?
Do you have a cardiac(heart) condition?
Do you have existing hypertension and are taking tablets?
Have you had Pre-Eclampsia in pregnancy prior to 24 weeks
Have you ever had a blood clot in your legs or lungs?
Do you have a rheumatological condition?
Have you ever had an organ transplant?
Have you ever had cancer?
Do you have a respiratory condition such as Asthma?
Do you have a gastroenterology condition, such as ulcerative colitis?
Do you have an endocrine condition, such as hypothyroidism?
Do you have chronic liver disease?
Do you have chronic kidney disease?
Have you received any antenatal care from another hospital during this pregnancy?
Do you have any communication needs e.g. hearing loss, visual impairment or learning disability?
Do you have sickle cell or thalassemia (trait or disease)?
If you have ticked ‘yes’ to this question, please contact the antenatal screening team by telephone on:
Royal Free Hospital 0207 794 0500 ext. 38961, Barnet Hospital 0208 216 4378 / 5140.
What medication/tablets are you regularly taking?
Are you a current smoker?
Is there anything else with your physical health that you think we need to know about?
Do you have a past or present Mental Illness?
If yes, please provide details:
Are you taking medication for this?
Have you had Previous Treatment or had Inpatient Care?
If yes, please provide details:
Do you have any other mental health concerns that you think we should know about?
PLACE OF BIRTH CHOICES
Please tick your preferred birth place choice *
The Royal Free London NHS Foundation Trust
Home birth (suitable for women with uncomplicated pregnancies who are generally fit and well), under the care of the Royal Free Trust incorporating these post codes: HA8 0, HA8 9,
    HA8 8, HA8 7, NW7 3, NW7 4, EN5, N20, N10, N11, N12, N2, N3, NW7 1, NW7 2, EN2, EN1, N14, N21, N13, EN4, EN6, WD6, NW9 4, NW9 5, NW9 6, NW9 7, NW2, NW8, NW6, W9,
    NW11, NW3 7, NW4, NW6, N6, N19, NW1, NW5, NW3.
OR
North Middlesex University Hospital
Thank you for your time. You will hear from us soon.
We look forward to meeting you.





Disclaimer
We share information with other professionals responsible for your care and will inform your GP that you have booked your maternity care with us.

For office use only

Date received:
Midwifery team:
Gestation when received:
LMP:
Age:
EDD:
GP informed:
PDS GP Practice Name:
PDS GP Address:
PDS GP Postcode:
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