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Maternity Referral Form

Congratulations on your pregnancy!

Please register your pregnancy using the form below and inform your GP.

Disclaimer: When completing this form please ensure that all mandatory fields are completed and that you provide us with your correct contact details. Please allow up to 10 working days for us to process your form1, after which you should receive your booking appointment date. If you have any queries regarding your referral please contact the Maternity Coordinator's Office on 01983 822099 ext 3210.

1 your midwife will usually contact you between 8-10 weeks gestation

 * denotes mandatory field

Please state whether you are a GP or pregnant woman*

1. Pregnant woman's details

I need an interpreter*

2. GP details

3. Current pregnancy information

Unsure of LMP
Do you have a raised BMI (i.e. above 30)?*

It is recommended you take 400 micrograms of folic acid from conception to 12 weeks of pregnancy, but if your BMI is over 30, you are diabetic, or taking medication for epilepsy you should take an increased amount of 5 mg a day. Please see your Midwife or GP.

It is also recommended you take 10 micrograms of Vitamin D throughout your pregnancy and when breast feeding.

4. Previous history

This information will enable us to work together to plan your care.



Are you having your first baby?*
Have you experienced any of the following?*

Medical history

History *

General Information

Are you a smoker?*

Giving up smoking will help you to have a healthier pregnancy. We will refer you to Stop Smoking Support unless you opt out.  

Do you consider yourself to have a learning disability?*
Alcohol or substance use*
Do you have any Child Protection/Social Care Involvement?*
Are you currently taking any medication? *
Do you have any allergies?*
Are there any other domestic or social circumstances you think we should be aware of?*

Please only click the ‘Submit’ button ONCE and wait patiently for the page that says 'Thank you for your submission'.

Please click on the link below to read 'Screening tests for you and your baby' before your first midwife appointment. (Further links are on the maternity pages.)

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