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.

I am completing this form
Patient's contact details
Previous name(s)
If no previous name, please leave blank.
Can the patient be contacted at this address by visit and by post?
Can a voicemail be left on the number provided?
Can SMS text reminders be sent for Community/Smoking in Pregnancy midwife appointments?
GP's name and address
Do you need an interpreter?
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.
Are you happy for us to contact your GP for any relevant maternity and medical history?
This allows us to arrange your first scan. 
Have you been pregnant before?
Is this an IVF pregnancy?
Are you transferring care from another hospital/NHS Trust?
Do you have any social, mental health or other risk factors?

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