North Devon Maternity Services Self-Referral Form

Intro

Welcome to North Devon Maternity Services. We are delighted to welcome you to our trust and Congratulations on your Pregnancy!

In order for us to understand your personal and individual needs, please fill in the *Self-Referral Booking Form and answer the questions below as best as you can.

Some questions are mandatory and you will not be able to submit the form unless answered.

Once you have submitted the booking form you will receive an on-screen confirmation to say your form submission has been successful.

If you have not received your booking appointment details with-in the 10 days specified or are experiencing any issues with the booking form please contact the Maternity Bookings Department on: rduh.maternitybookings@nhs.net

*Please note this form is for Northern Services including Barnstaple and the surrounding North Devon area only

For Eastern services including Exeter and the surrounding area please refer to our service by contacting the community team linked to your GP surgery, by clicking this link and selecting the ‘Community Midwives tab’ option.

Your details

Title *

First name *

Surname *

Maiden name or previous surnames

Date of birth *

NHS Number (If known)

Help to find your NHS number

Help to find your NHS number - click here

Address *

Postcode *

Preferred contact telephone number *

Email address *

Repeat email address *

If 'Other' please specify

Do you require a language interpreter? *

Yes

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

Please state what assistance is required

First day of your Last Menstrual Period

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

Was this pregnancy conceived via IVF?

Yes

Number of previous pregnancies *

Number of children *

Was a donor egg used?

Yes

What was the age of donor at donation?

Was donor sperm used?

Yes

What was the date of embryo transfer?

Folic acid

Important Folic Acid Information – Please read

It is important to take a 400 microgram folic acid tablet every day until you are 12 weeks pregnant, alongside 10 micrograms of vitamin D. Some women need a higher dose of folic acid, please click here

Your current/past medical history

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

Yes

Your health

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

Yes

Which type do you have?

Type 1

Type 2

Gestational

Do you have the medical condition epilepsy *

Yes

Are you currently on medication for your epilepsy

Yes

Do you smoke tobacco? *

Yes

Your GP details

Name of your GP practice you are currently registered with *

Are you newly registered with the GP?

Yes

Are you transferring care from another area with-in the UK or Abroad *

Yes

Please specify which area and country

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

Name of hospital/birth centre you are currently booked with

Next of Kin/Alternate Contact Person

Next of kin/alternate contact person

First name

Surname

Relationship to you

Contact number - Home/mobile *

Is this person your emergency contact that can be notified on admission?

Yes

Please give details

Your first appointment

Second preference text after question

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

I am *

The patient

The patient's carer/advocate

By submitting this form you will automatically be signed up for the MyCare MyChart app.

I am currently registered with MY CARE

confirmation following text

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

Notice

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.