NHS Royal Devon | North Devon Maternity Services Self-Referral Form

Welcome to North Devon Maternity Services. To enable us to provide you with the best possible care for you and your baby please could you complete the maternity self-referral form.

In order for us to understand your individual needs, please answer all relevant questions giving as much detail when stated.

Once your form has been submitted you will receive an instant automated email reply to notify you that your form has been received by the maternity bookings department.

Please allow 14 days for your booking appointment to be made.

Please ensure to check your junk mail box and if you haven't received a reply from us within the 14 days specified, please call the Maternity Booking Department on 01271 341500

Your details

Title *

First name *

Surname *

Maiden name or previous surnames

Date of birth *

Address *

Postcode *

Preferred contact telephone number *

Email address *

Ethnicity *

Do you require an Interpreter *

Yes
No

If you have answered yes to the previous question, please state which language is required

Do you have any additional requirements that we need to be aware of *

Yes
No

Please state what assistance is required

First day of your last period (LMP) *

GP name

GP surgery *

Number of previous pregnancies *

Number of children *

Do you or the biological father of your unborn baby have any family history of hereditary/genetic conditions *

Yes
No

Please give details

Are you transferring your maternity care from a different hospital *

Yes
No

Please state your baby’s due date

Have you registered with a new GP if so, please give details

Do you currently have Gestational/Type 1 or Type 2 diabetes? *

Yes
No

Which type do you have?

Type 1
Type 2
Gestational

Do you have the medical condition epilepsy *

Yes
No

Are you currently on medication for your epilepsy

Yes
No

Do you Smoke? *

Yes
No

Have you quit smoking since conception?

Yes
No

Are you on Nicotine Replacement Therapy? or Vaping as part of a quit attempt? *

Yes
No

Where would you prefer your midwife antenatal care appointments to take place? First preference - *

Where would you prefer your midwife antenatal care appointments to take place? Second preference - *

I am *

The patient
The patient's carer/advocate

Would you like to register for the new My Care app? This will give you access to your maternity notes; appointments; test results and can provide you with access to contact healthcare professionals. *

Yes
No

Services

North Devon Maternity Services Self-Referral Form

Your details

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