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Bournemouth Hospital self-referral
Bournemouth Hospital self-referral
Nathan Revill
2020-01-30T19:41:05+00:00
Online self-referral form
Please complete the form below with as much detail as possible, as this will enable us to process your referral more quickly. Your referral will then be processed, and you will be contacted by a community midwife to arrange a booking appointment, by 12 weeks of pregnancy. We will also advise your GP that you are pregnant, so you do not need to, as we are obliged to let them know we are caring for you.
*Mandatory question
Personal information
Your full name*
Full name
Field is required!
Field is required!
Any previous surname(s) if applicable
Previous surname(s)
Field is required!
Field is required!
Your date of birth*
dd/mm/yyyy
Field is required!
Field is required!
Address*
Address line 1*
Field is required!
Field is required!
Address line 2
Field is required!
Field is required!
Town*
Field is required!
Field is required!
Postcode*
Field is required!
Field is required!
Mobile phone number*
Please provide your mobile phone number and we will text you with pregnancy information.
Enter mobile telephone
Field is required!
Field is required!
Home phone number*
Enter home telephone
Field is required!
Field is required!
Email address*
Enter your email address
Field is required!
Field is required!
What is your ethnic origin?*
Select ethnic origin
White British
White Irish
White and Black Caribbean
White and Black African
White and Asian
Indian
Pakistani
Bangladeshi
Black Caribbean
Black African
Other Black
Any other ethnic group
Prefer not to say
Select ethnic origin
Field is required!
Field is required!
Is English your first language?*
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
Have you lived in the UK for last 6 months?*
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
If ‘No’ what is your first language?
Enter your first language
Field is required!
Field is required!
Do you need interpretation services at your booking appointment?
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
GP & Next of kin
NHS number
Each NHS Number is made up of 10 digits shown in a 3-3-4 format.
Enter NHS number (if known)
Field is required!
Field is required!
Hospital number
Enter hospital number (if known)
Field is required!
Field is required!
Your GP's address
- select a option -
Abbotsbury Road Surgery
Banks & Bearwood Med Practice
Barton House Surgery
Beaufort Road Surgery
Bere Regis Surgery
Blackmore Vale
Bridport Medical Centre
Bute House Surgery
Canford Heath Group Practice
Carlisle House Surgery
Cerne Abbas Surgery
Christchurch Medical Practice
Corfe Castle Surgery
Cross Road Surgery
Denmark Road Med Centre
Dorchester Road Surgery
Eagle House Surgery
Evergreen Oak Surgery
Family Medical Services (Dr Newman's Surgery)
Fordington Surgery
Gillingham Medical Practice
Heatherview Medical Centre
Highcliffe Med Centre
James Fisher Med Centre
Kinson Road Med Centre
Leybourne Surgery
Lilliput Surgery
Littledown Surgery
Longfleet House Surgery
Lyme Bay Medical Practice
Lyme Regis Medical Centre (Virgin HC)
Marine & Oakridge Pship
Milton Abbas Surgery
Moordown Med Centre
Newland Surgery
No of practices
Old Dispensary
Orchid House Surgery
Panton Practice (Gervis Road Practice)
Parkstone Tower Practice
Penny's Hill Practice
Poole Road Medical Centre
Poole Town Surgery
Portesham Surgery (Malthouse Meadows Surgery)
Poundbury Doctors Surgery (Cornwall Road)
Prince of Wales Surgery
Providence Surgery
Puddletown Surgery
Queens Avenue Surgery
Rosemary Medical Centre
Royal Crescent and Preston Road Surgery
Royal Manor Health Care
Sandford Surgery
Shelley Manor and Holdenhurst Med Centre
Southbourne Surgery
St Albans Med Centre
Stalbridge Surgery
Stour Surgery
Swanage Medical Centre
Talbot Med Centre
The Adam Practice
The Alma Partnership
The Apples Medical Centre
The Atrium Health Centre
The Barcellos Family Practice (Formerly Corbin Avenue Surgery)
The Birchwood Medical Centre
The Bridges Medical Practice
The Charmouth Medical Practice
The Cranborne Practice
The Farmhouse Surgery
The Grove Surgery
The Hadleigh Practice
The Harvey Practice
The Quarter Jack Surgery
The Tollerford Practice
Verwood Surgery
Village Surgery
Walford Mill Medical Practice
Wareham Surgery
Wellbridge Practice
Wessex Road Surgery
West Moors Group Practice
Westbourne Medical Centre
Whitecliff Group Practice (Dr Evans and Partners)
Woodlea House Surgery
Wyke Regis and Lanehouse Medical Practice
Yetminster Health Centre
- select a option -
Field is required!
Field is required!
If your GP address is not listed, please enter it below
Enter GP's address...
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Field is required!
Do you have a partner?*
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
If yes, please provide their full name
Enter name
Field is required!
Field is required!
Is your partner your next of kin?*
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
If no, please provide your next of kin’s full name
Enter next of kin name
Field is required!
Field is required!
Your Next of kin's phone number*
Enter next of kin phone number
Field is required!
Field is required!
What is your relationship with the next of kin?
Enter relationship of next of kin
Field is required!
Field is required!
Your next of kin's address
Next of kin address line 1
Field is required!
Field is required!
Next of kin address line 2
Field is required!
Field is required!
Town
Field is required!
Field is required!
Postcode
Field is required!
Field is required!
History
What was the date of the first day of your last menstrual period?*
If unknown, please put closest known date
Select date
Field is required!
Field is required!
What was the date of the first positive pregnancy test?
REMEMBER: You must be more than 6 weeks pregnant to refer to the maternity service*
Select date
Field is required!
Field is required!
How many times have you been pregnant before?*
REMEMBER: Please include any previous miscarriages or terminations.
Enter number
Please enter a numeric value (0, 1, 2 etc.)
Please enter a numeric value (0, 1, 2 etc.)
How many children do you have?*
Enter number
Please enter a numeric value (0, 1, 2 etc.)
Please enter a numeric value (0, 1, 2 etc.)
Is your partner the babies father?*
- select a option -
Yes
No
Uncertain
- select a option -
Field is required!
Field is required!
Have you been taking Vitamin D?
(We recommend taking 10 mcg a day of Vitamin D throughout pregnancy) Yes/No
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
Have you been taking folic acid?
(We recommend taking 400 mcg a day of folic acid, however if your BMI is 30 or over please see your GP for a higher dose) Yes/No
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
Do you have diabetes?
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
Is there any family history of genetic disorders?
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
If yes please provide details
Enter details
Field is required!
Field is required!
Do you smoke?
Select yes or no
Yes
No
Select yes or no
Field is required!
Field is required!
Additional information
Where are you planning to have your baby?
Select an answer
Bournemouth Hospital Birthing Centre
Dorset County Hospital Maternity Unit
Poole Maternity Unit
Home Birth
Undecided
Other (Please specify in extra details form below)
Select an answer
Field is required!
Field is required!
Please use the box below to provide any extra details
Enter any additional information...
Field is required!
Field is required!
Please allow up to ten working days for us to process your booking.
Please note: you may be emailed your appointment, so please ensure you check your junk mail regularly.
When you press submit, this form will be sent to Rbc-tr.rbch.communitymidwives@nhs.net
Submit
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