Maternity Booking - Online Self Referral form

This information can only be accessed by Maternity Team in order to protect your patient confidentiality.

Please ensure all the fields marked * are  filled in correctly.
Contact details
  *Surname :
  *First name :
Previous Surname:
  *Date of Birth : (dd/mm/yyyy)
Hospital no (if known):
NHS No (if known):
  *Address :
  *Postcode :
  *Contact no:
  *Email address:

GP details
  *GP's Name:
  *Practice name:
Telephone no:

Personal details
Marital status:
Ethnic group:
Language spoken:
Do you require an Interpreter?
(Family members should not be used)
First day of your last menstrual period
Number of weeks pregnant?
*Have you booked at another hospital ?  
Name of hospital/birth centre you are currently booked at 
*Have you been to the Whittington before?  

Past history
*Have you been pregnant before?  
If yes, how many times:

Current history
Please specify
Please specify