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North Devon Maternity Services Self-Referral Form

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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 *

NHS Number (If known)

Address *

Postcode *

Preferred contact telephone number *

Email address * Please note this is a mandatory requirement as you will be contacted via email with your first booking appointment details

What gender do you identify as? *

If 'Other' please specify

Ethnicity *

Do you require an Interpreter * Please note should you require an interpreter, we will use language line. We advise that family members, or friends, are NOT permitted as interpreters during your appointment.

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 * (e.g. mobility, sight, hearing)

Yes
No

Please state what assistance is required

First day of your last menstrual period

If unsure of the exact date of your last menstrual period, please give a rough estimate as to the amount of weeks pregnant you think you might be, this will help us to plan your care appropriately.

Date of Last Menstrual Period

Number of weeks pregnant

Your GP details

GP name

GP surgery *

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

Next of kin/alternate contact person

Name

Relationship to you

Contact Telephone Number

Your current/past medical history

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 * e.g. Cystic Fibrosis / Sickle Cell or Thalassaemia

Yes
No

Please give details

Are you transferring your maternity care from a different hospital *

Yes
No

If you have answered yes, please provide your EDD date (Estimated Date of Delivery)

Name of hospital/birth centre you are currently booked with

Your health

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

Your first appointment

Where would you prefer your midwife antenatal care appointments to take place? First preference - * There may be rare occasions when there are no clinic spaces available in your chosen area due to demand of maternity services. In this event we will book you into the midwifery clinic nearest to your given preference.

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

There may be rare occasions when there are no clinic spaces available in your chosen area due to demand of maternity services. In this event we will book you into the midwifery clinic nearest to your given preference. THIS CHOICE MUST BE DIFFERENT FROM YOUR FIRST PREFERENCE

Additional Comments Please add any comments here that will be relevant to your booking appointment

I am *

The patient
The patient's carer/advocate

By submitting this form you will automatically be signed up for the MyCare MyChart app. This will give you access to your Healthcare Records; Maternity Notes; Upcoming and Past Appointments; Test Results and will also provide you with access to contact Healthcare Professionals and Community Midwives. Once you have registered with the MyChart app you must accept Notifications to enable appointments and results to be sent to you directly

Select to opt out

Confirmation *

I can confirm all the information I have provided is correct

FAILURE TO DO SO MAY RESULT IN APPOINTMENTS BEING DELAYED AND MAY AFFECT THE CARE OF YOU AND YOUR BABY

Our NHS Trust collects and manages your personal data/information; we only share this information with other NHS and non-NHS organisations in order to support your care. You can find out more about how we process your data by going to our Trust website and looking at our privacy notice

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Get in contact

If you have any urgent health concerns, think you are in labour, or are worried about your baby’s movements, please contact us at any time, 24 hours a day, 7 days a week.

01392 406616

Please contact this number for both the Royal Devon and Exeter Hospital and North Devon District Hospital.

We provide emergency care and advice to families, midwives and GPs in all areas of antenatal, labour and postnatal care.