GP maternity referral form

The Royal Free London NHS Foundation Trust has full maternity services at The Royal Free Hospital in Hampstead and at Barnet General Hospital in Barnet. 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.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 Royal Free, Barnet, Edgware and Community Hubs.

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.
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For office use only

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