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...
Field is required!
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
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