Maternity self referral form

If you would like to book your pregnancy with us and have a Rotherham address, you can self-refer using our online referral form and one of the Maternity Team will contact you to arrange an appointment.

You will need your NHS number to complete this referral form.

Find your NHS number

I am completing this form

as a patient

on behalf of someone else

If you are completing this from on behalf of somebody else, please state your relationship to patient.

Patient's contact details

First name and surname

Email

Phone

Address

Address 2

City/Town

Postal Code

Patient's date of birth

Previous name(s)

If no previous name, please leave blank.

First

Last

Can the patient be contacted at this address by visit and by post?

Yes

No

Can a voicemail be left on the number provided?

Yes

No

Can SMS text reminders be sent for Community/Smoking in Pregnancy midwife appointments?

Yes

No

Please provide the patient's NHS number

GP's name and address

GP name

Practice name

Address

Address 2

City/Town

ZIP/Postal Code

Where would you like to give birth?

Family origin of the patient?

Do you need an interpreter?

Yes

No

Please note, friends and family members may not be interpreters. If you fail to request an interpreter when it is required, this may result in appointments being delayed or cancelled.

If you do need an interpreter, please state your spoken language.

Are you happy for us to contact your GP for any relevant maternity and medical history?

Yes

No

Please tell us the date of day 1 of your last menstrual period.

This allows us to arrange your first scan.

Have you been pregnant before?

Yes

No

If yes, how many children do you have?

Please give details of any pregnancy history.

Is this an IVF pregnancy?

Yes

No

Are you transferring care from another hospital/NHS Trust?

Yes

No

If yes, please explain why.

Please give details of your medical history.

Please give details of any current medications

If yes, please provide details.

Please give us details of any dates we should avoid when booking your appointments.

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