You're pregnant

So that we can make your first appointment to meet us, please complete the self-referral form providing as much information as possible. Questions marked with an asterisk are mandatory.

Details of your midwife booking appointment will be emailed to you within seven working days. Please do not contact the booking coordinator unless you have not heard from us in seven working days.

If you have difficulties completing this form, or have not received your midwife booking appointment, contact the booking coordinator on 01483 571122 ext. 4749.

If you have any urgent pregnancy concerns e.g. bleeding, pain, please call 24/7 advice line Call a Midwife on 0300 123 5473.

Online referral form

Note: Questions marked by * are mandatory

Royal Surrey NHS Foundation Trust privacy notices and data security statements can be viewed on our Information Governance webpages.​​​​​​​ You can view our Information Governance page by clicking here.

*This is a mandatory field. First name: This should be as it appears in your NHS record.

*This is a mandatory field. Surname:

Previous name:

*This is a mandatory field. Date of birth:

*This is a mandatory field. Address - house name/number:

Address line 2:

*This is a mandatory field. Address - town/city:

*This is a mandatory field. Address - post code:

*This is a mandatory field. Do you consent for us to use your email and mobile number to set up your BadgerNotes account (this is where you can access your electronic maternity note) as well as to make contact with you about your referral?

Yes
No

*This is a mandatory field. Telephone number:

*This is a mandatory field. Email address:

*This is a mandatory field. NHS number: This should be 12 characters long e.g. 123 456 7890 Your NHS number can be found on any hospital letters, on your NHS app, via contacting your GP surgery or via the NHS checker: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

*This is a mandatory field. GP surgery/practice:

*This is a mandatory field. Are you transferring your care from another hospital?

Yes
No

If you are transferring your care please tell us which hospital you are transferring from.

*This is a mandatory field. First date of last period:

Have you had a scan in this pregnancy?

Yes
No

*This is a mandatory field. Ethnicity:

Please Select An Option Asian – Any Other Asian BackgroundAsian – Bangladesh or British BangladeshAsian – Indian or British IndianAsian – Pakistani or British PakistaniBlack – African or British AfricanBlack – Any Other Black BackgroundBlack – Caribbean or British CaribbeanChineseDeclined/ Refused to give informationMixed – Any Other Mixed BackgroundMixed – Asian and WhiteMixed – Black African and WhiteMixed – Black Caribbean and WhiteOther Ethnic GroupUnable to be asked/ ReplyWhite – Any Other White OriginWhite – BritishWhite - Irish

Do you require an interpreter?

Yes
No

What language do you need an interpreter for?

Please provide additional information relevant to your maternity care e.g. known pregnancy risk, expecting twins. (If you have immediate concerns call the pregnancy advice line on 0300 123 5473)

*This is a mandatory field. I confirm that I have checked the answers in this form and all my details are correct.

Yes
No