Self-referral form for maternity services

The Royal Free London NHS Foundation Trust has maternity services at Barnet Hospital and the Royal Free Hospital.
If you would like to have your baby with us, please fill out this form.
Fields marked with an asterisk are mandatory.

Surname: *
First name: *
Previous name:
Address: *
Post code: *
Telephone: *
May we call you on this number about your referral?
Date of birth: *
 
Age:
NHS no. (if known):
Email:
May we contact you on this email address about your referral?
Mobile telephone:
May we call you on this number about your referral?
May we text you on this number about your referral?

The Royal Free London NHS Foundation Trust has maternity services at Royal Free, Barnet, Edgware and Community Hubs.

GP practice/surgery:*
Address:
Post code:
Are you happy for us to contact your GP?*
Do you need an interpreter?
What language do you need an interpreter for?
Ethnic group:
Have you lived in the UK for longer than 6 months?
What date was the first day of your last period?
 

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

In order to identify pathway of care please mark the options below that apply to you:

Past Pregnancies:

Is this your first pregnancy?

Have you had 3 or more miscarriages?

Have you experienced losing a baby when you were more than 5 months pregnant (20 weeks)?

Medical history:

Do you have an existing disease/illness that you have regular treatment/medication for?

If yes, please provide details of treatment/medication:

Do you have sickle cell or thalassemia?

If you ticked 'yes' to having sickle cell or thalassemia, please contact the screening team by telephone on Royal Free 0207 794 0500 ext. 38961, Barnet 0208 216 4378 / 5140)

  


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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