Referral to Bradford Maternity Services – Bradford Teaching Hospitals NHS Foundation Trust

Congratulations on your pregnancy.
By completing this form you are arranging your maternity care at Bradford Women’s and Newborn Unit. You can choose to birth your baby at home or in the hospital, when you meet your midwife you can discuss your choices further.
To avoid a delay in your care please make sure you complete all mandatory fields.
If you have any difficulties understanding or completing this form please contact your GP surgery to make a referral for you.

Maternity Self Referral with Bradford Teaching Hospitals NHS Foundation Trust's Maternity services.

Fields marked with * are required

Where would you like to birth your baby?*

FIRST NAME*

SURNAME*

PREVIOUS SURNAME

DATE OF BIRTH*

NHS number*

Find your NHS number (This link provides help finding your NHS number)

Ethnicity*

Are you completing this form on behalf of someone?

YesNo

Do you need an interpreter?*

YesNo

accessible Do you have any access requirements we need to be aware of*

YesNo

House/Flat Number*

1st Line of Address*

Post Code*

Previous address (if known)

Home Phone Number.

Mobile Number*

Do you give your consent for us to use these telephone numbers?*

YesNo

Do you give consent for us to share information with other health professionals involved in your care?*

YesNo

Have you had a positive pregnancy test?*

YesNo

Do you know when your last menstrual period (LMP) was*

YesNo

Would you consider birthing your baby at home or would like more information about this?

YesNo

Do you have any Allergies*

GP's Name*

GP Telephone Number*

GP Practice Name*

GP Address*

Previous Pregnancy History	Yes	No
Is this your first pregnancy?*	Yes	No
Have you had a caesarean section?	Yes	No
Have you had a vaginal birth since your caesarean section?	Yes	No
Have you had a baby born before 34 weeks of pregnancy?	Yes	No
Have you had a previous pregnancy loss after 12 weeks?	Yes	No


How many pregnancies have you had?
How many children do you have?

Previous Medical History	Yes	No
Do you have diabetes?	Yes	No
Do you have breathing problems such as severe asthma?	Yes	No
Do you have epilepsy?	Yes	No
Have you had an ectopic pregnancy?	Yes	No
Do you have high blood pressure?	Yes	No
Do you have heart disease?	Yes	No
Do you have kidney disease?	Yes	No
Do you have mental health problems?	Yes	No
Have you had a blood clot in your legs or lungs, eg. DVT?	Yes	No
Do you have a blood disorder, eg. Sickle cell or thalassaemia?	Yes	No
Do you have any other conditions you need to see a GP or consultant about?	Yes	No
Do you take any regular medication?	Yes	No
Is there anything else you think we need to know about you?	Yes	No
Please provide brief details on what we may need to know

Social Services History	Yes	No
Do you currently have or have you previously had any involvement with Social Services?	Yes	No

Contact Preferences

What is your preferred method of contact?*

Can we send letters to your address?

YesNo

Email Address*

A confirmation email will be sent to this address