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

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


(e.g. mobility, sight, hearing)


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.

Your GP details

Next of kin/alternate contact person

Your current/past medical history

e.g. Cystic Fibrosis / Sickle Cell or Thalassaemia




Your health













Your first appointment

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


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


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

Last updated: June 23, 2023.

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