Pregnancy Self-Referral Form

Please take, post or fax this Form to the Antenatal Booking Office

1st Floor Lanesborough Wing

St Georges Hospital, Blackshaw Road SW17 0QT

Fax: 0208 725 – 3302 Tel: 0208 725 – 1914 or 1710

Step 1: Please read through the form complete all sections; shaded sections are essential.

Step 2: Please bring completed form to the antenatal booking office (Monday to Friday only 9am -4pm) (details above).

Step 3: If you attend or have an Early Pregnancy Scan – Please bring the scan report with this self referral

Surname: / Date of Birth: dd/mm/yy
First Name: / Hospital No (if known):
Previous Surname: / NHS No (if known):
Address:
Post code: / Age:
Home Tel: / Mobile Tel:
Can we contact you on this number by text messaging? / YES ¨ NO ¨ / Date completed form: e.g. 01/01/2016)
GP Name:
Practice Name:
Address:
Post Code: / Gender / FEMALE
Marital Status: / Nationality:
Do you require an Interpreter? / YES ¨ NO ¨ / Country of Birth e.g. UK
Language spoken: / Religion:
First day of your last period Last Menstrual Period (LMP)? / Please tell us when your baby is due
(EDD) / /201
Have you had a scan? YES ¨ NO ¨ / Date scan was done / / 201
Height: / Weight:
Next of kin details
Surname: / First Name:
Address:
Post code: / Mobile Tel:
Home Tel: / Work Tel:
Please complete the shaded section below only if you are Transferring Hospital
How many weeks pregnant are you? (e.g. 20 weeks) / Have you booked at another hospital? / YES ¨ NO ¨
Name of hospital/birth centre you are currently booked at:
At St Georges we actively promote Normal Birth, please see below the options we have available for birth place.
Please discuss with your midwife at the first antenatal visit
Home Birth (Wandsworth area & defined area in Merton only) / Care provided by Rainbow Team a dedicated Home Birth Team; contact the midwives direct on 0208 725 -2537
Carmen Birth Centre(Midwifery Led Birth Unit) / Midwifery Led care provided to low risk women
Delivery Suite / Birthing area providing a combination of low and high risk care

[NB: If you are transferring your care, please bring your notes from your current hospital with you.]

Self Ref/V9/2016