Maternity Booking - Online Self Referral form

Congratulations on your pregnancy!

Please fill in the form below to refer yourself for pregnancy care at the Whittington.

If you have any difficulties using the form, please call us on 020 7288 3482.

Please note – your information can only be accessed by the Maternity team and is protected for patient confidentiality.

Please ensure all the fields marked* are filled in correctly.

Type ‘not sure’ if you don’t have the information.

Your contact details

Surname* !

First name* !

Previous surname

Date of Birth*(dd/mm/yyyy) !

NHS Number* !

You can find your NHS number here

Have you been treated at the Whittington before?* !

Yes

Address and Postcode* ! !

Phone number* !

Email address* ! !

Do you have problems accessing the internet?* !

Yes

Your GP details

GP Name* !

Practice Name* !

Address

Telephone Number

Your personal details

Nationality* !

Religion* !

Do you require an interpreter? (including British Sign language)* !

Yes

Language spoken* !

Date of your last menstrual period*

If unsure of the exact date, please give an estimated date so we can plan your care appropriately.

If you have used assisted conception and don’t have a last menstrual period date, please provide us with an estimate of how many weeks pregnant you are

Are you currently booked at another hospital?* !

Yes

if yes, please provide Estimated Date of Delivery (EDD)

Name of hospital you are currently booked at

Medical history

Do you have any of the following?*

Diabetes Type 1/2

High blood pressure

Mental Health problem e.g., depression, anxiety, eating disorder

None of the above

Please select at least one item.

If you ticked any of the above, please provide brief details including any current medication

(if you currently take any medication for your mental health, please do not stop taking this due to the pregnancy)

Do you have any needs related to mobility, sight, hearing, learning disabilities or anything else that we should be aware of?* !

Yes

If yes, please provide further details

Do you or the father of the baby have any sickle cell disease/thalassemia or traits of either? * !

Yes

If yes, please provide further details