Maternity Self-Referral | Hull University Teaching Hospitals NHS Trust

Book in with the midwives and they will arrange your first appointment with a community midwife:

Unique ID
Do you want to book for your care at Hull University Teaching Hospitals NHS Trust?*
- Yes
- No
Sorry, we can only take referrals from women wanting to deliver their babies in Hull.

You may find what you're looking for at one of the following hospitals:

NHS Number

Please provide this if you know it.
Title*
- Miss
- Mrs
- Ms
Forename(s)*
Surname*
Previous name(s) you have used
Age*
Date of Birth*
Ethnic Origin*
Is English your first language?*
- Yes
- No
What is your first language?*
Do you require an interpreter?*
- Yes
- No
Do you have a hearing, sight or learning disability which will affect how we communicate with each other?*
- Yes
- No
Please give us specific details and tell us anything that you think would be helpful when we are communicating with you.*
How long have you lived in the UK?*
Current Address*
If this is a different address to the one held by your GP practice, please contact your GP practice as soon as possible to give them your current address.

Street Address Address Line 2 Town / City County Postcode Country
Have you lived at this address for less than 12 months?*
- Yes
- No
Previous Address*
We need to know your previous address as you have lived at your current address for less than 12 months.

Street Address Address Line 2 Town / City County Postcode Country
Phone Number*
Would you like to use our mobile service using text alerts for appointments?*
- Yes
- No
Email Address*
Do you have any holidays booked for the next month?*
- Yes
- No
What are the dates of your holiday(s)?*
How many weeks pregnant do you think you are?*
Please give your best guess.
You are 12+ weeks pregnant. How many weeks exactly?*
Please give your best guess.
What was the date of your last period?
Please provide this information if you know it.
Are you already booked at another hospital and are transferring your care?*
- Yes
- No
Which hospital are you transferring your care from?*
Is this your first baby?*
- Yes
- No
Where was your last baby born?*
Please specify where:*
Tell us what type(s) of delivery you have had with your previous child(ren)?*
You can select more than one option if you have had more than one type of delivery.
- Normal Birth
- C-Section
- Forceps / Ventouse Assisted
Please provide any significant details about any previous pregnancies.
This might include Caesarean section, premature birth, blood pressure issues, complications, etc.
Please provide the full names and dates of birth of your other children.*
Do you drink alcohol?*
- Yes
- No
What is your average weekly alcohol intake?*
You can use a handy tool to calculate your average weekly alcohol intake now.
Do you smoke?*
- Yes
- No
Do you want to be referred for help with quitting?*
- Yes
- No
What is your BMI (Body Mass Index)?*

Folic Acid is recommended until 12 weeks of pregnancy to reduce the risk of neural tube defects. The dosage required is dependent on your Body Mass Index (BMI) which you can work out using the BMI Healthy Weight Calculator (opens in new window). If your BMI is under 30 you require 400 micrograms of Folic Acid daily, which you can buy from your pharmacy. If your BMI is 30 or over you require 5mg daily. You need to request this from your GP. Please take this opportunity to access important pregnancy specific health information in our Healthy Lifestyles (opens in new window) section.
Are you taking Folic Acid currently?*
- Yes
- No
What dose of Folic Acid are you currently taking?*
- 400mcg
- 5mg
Are you taking Vitamin D currently?*
- Yes
- No
We advise that you start to take 10mcg Vitamin D daily.
Do you have Ashermans Syndrome (scar tissue inside the uterus causing walls to stick together)?*
- Yes
- No
Have you ever had surgery on your cervix?*
- Yes
- No
Please give details of the surgery on your cervix.*
Have you ever been told you have an irregular shaped uterus (womb)?*
- Yes
- No
Have you ever had a pre-term labour?*
- Yes
- No
Was this before 34 weeks?*
- Yes
- No
Have you ever had an emergency c-section when fully dilated?*
- Yes
- No
Have you ever had cervical cancer?*
- Yes
- No
Have you ever had a stitch in your cervix?*
- Yes
- No
Do you have any significant medical conditions or history we need to know about?
If you have significant medical history, please obtain a printout via your GP receptionist listing your current medication, allergies and relevant history. Please bring this to your booking appointment with a midwife.
GP Name*
GP Address
A copy of this form will be sent to your GP.

Street Address Address Line 2 Town / City County Postcode Country
GP Phone Number
Are you the patient?*
- Yes - I am the patient
- No - I am completing this referral on behalf of the patient
What is your name?*
What is your relationship to the patient?*
Do you consent to the processing of your personal data as per the information at the top of this form?*
- Yes, I consent to the processing of my personal data
Comments
This field is for validation purposes and should be left unchanged.

What will happen after I submit a maternity self-referral?

Your referral will be sent via email to hyp-tr.direct.access@nhs.net where it will be processed by the maternity clerical team.
You will receive an email confirming that you have completed the referral, but the email will not include a copy of your confidential information.
Your referral will be uploaded to your hospital patient record.
You should receive a letter inviting you to see a midwife some time after you have reached your 8th week of pregnancy.

How we protect your data

By completing and submitting this form, you (or your representative, on your behalf) are consenting to the processing of your information for this service. We will ensure your personal information is secured using SSL (Secure Socket Layer) encryption which provides a secure link between our website and your browser. This ensures that all data passed between us remains private and can be verified by the https:// and padlock symbol that appear in the address bar. After submission, your personal information is handled according to our trust policies and Data Protection Legislation. Find out more about how we process your confidential information.