GP maternity referral form

The Royal Free London NHS Foundation Trust has marternity services at Barnet Hospital and the Royal Free Hospital.
To refer to the Royal Free London, please fill out the following form. Fields marked with an asterisk are mandatory.

Surname: *
First name: *
Previous name:
Address: *
Post code: *
Telephone: *
Date of birth: *
 
Age:
NHS no. (if known):
Email:
Mobile telephone:

The Royal Free London NHS Foundation Trust has maternity services at Barnet Hospital and the Royal Free Hospital. Which of our maternity services would you like to refer to? *

GP practice/surgery: *
GP practice email: *
@nhs.net
Address:
Post code:
Does the patient require an interpreter?
What language would patient need an interpreter for?
What date was the first day of the last period?
 

Have they had a baby at the Royal Free London previously? Please note that Royal Free London maternity services include Barnet Hospital, Edgware Birth Centre and the Royal Free Hospital.

Does the patient have any relevant medical history?
Click here  to attach supporting medical records.
LinkButton

For office use only

Date received:
Midwifery team:
Gestation when received:
LMP:
Age:
EDD:
GP informed:

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