Online self-referral form for Maternity Services

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> Online self-referral form for Maternity Services

Online self-referral form for Maternity Services

About you

Note: Questions marked by * are mandatory

Please complete this form, giving as much detail as possible so that we can ensure the best pathway for your maternity care. The information you provide will be placed in your medical records and only accessed by staff involved in your care.

*This is a mandatory field. I am completing this form as a...

Patient
Admin team member
Other

If you selected other in the previous question, please state relationship to patient

*This is a mandatory field. In which hospital would you like to receive your care? Please note if you do not select a preferred option we will allocate you to your nearest hospital

University Hospital Lewisham
Queen Elizabeth Hospital Greenwich
Do not know

*This is a mandatory field. Where would you like to give birth?

*This is a mandatory field. First name

*This is a mandatory field. Surname

*This is a mandatory field. Previous name(s) If no previous name please write NONE

*This is a mandatory field. Date of birth

*This is a mandatory field. Address

*This is a mandatory field. Post code

*This is a mandatory field. Contact number

*This is a mandatory field. Email address

Mobile number (your appointment information will be sent to this number)

NHS Number (if known)

Hospital number (if known)

Emergency contact details / Relationship

*This is a mandatory field. Name and address of your GP

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

Yes
No

*This is a mandatory field. Did you see your GP about this pregnancy prior to making this referral?

Yes
No

*This is a mandatory field. Family origin of mother

White British
White Irish
White Other
Black Caribbean
Black African
Black British
Black Other
Indian
Sri Lankan
Bangladeshi
Thai
Pakistani
Chinese
Malaysian
Asian Other
White & Black Caribbean
White & Black African
White & Asian
Mixed Other
Any Other

*This is a mandatory field. Do you need an interpreter? Please note: Friends and family members are not permitted as interpreters. If you fail to request an interpreter when it is required, this may result in appointments being delayed or cancelled

Yes
No

If you answered yes to the previous question, please state your spoken language

*This is a mandatory field. Have you been in the UK for more than 1 year?

Yes
No

If you answered no to the previous question, please provide details

Height (m)

Weight (kg)

BMI

Do you smoke?

Yes, I currently smoke
No, I have never smoked
No, but I am an ex-smoker

Does anyone in your household smoke?

Yes
No

*This is a mandatory field. Are you or your household currently self-isolating due to Covid-19?

Yes
No

If you answered yes to the previous question, please give details, including why you are self-isolating (ie whether you or someone else has symptoms or is a confirmed case of Covid-19) and the date you started self-isolating

Have you travelled abroad or arrived in the UK within the last 14 days?

Yes
No

If you answered yes to the previous question, what date did you arrive/return in the UK? * Please be aware as per government laws introduced on 8 June 2020, you must quarantine for 14 days on entrance to the UK.

Please see the gov.uk website for more information: https://www.gov.uk/uk-border-control

Are you currently shielding having received a Government/medical letter advising you to do so?

Yes
No

If you answered yes to the previous question, please provide details below.

Is anyone in your household currently shielding having received a government/medical letter advising them to do so?

Yes
No

If you answered yes to the previous question, what relation are they to you and please provide details

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