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Self-referral service for Lancashire Teaching Hospitals ( Includes Royal Preston Hospital and Chorley and South Ribble Hospital)

As soon as you find out you are pregnant you have the option to book your maternity care directly with Lancashire teaching Hospitals instead of seeing your GP; we encourage you to do this as soon as possible so you can see your midwife and have your early screening tests.

Note: Questions marked by * are mandatory

Please answer the questions as fully as possible as this will enable us to ensure you receive the most appropriate care.

When you submit the form our booking team will arrange your first booking appointment and also notify your GP of your pregnancy.

It is now routine practice for women to be seen on their own for the first 10 minutes of their appointment

If you do not receive an appointment within 2 weeks then please call us on 01772 524726

Folic acid

It is recommended that you start taking Folic acid (0.4mg) supplements as early in pregnancy as possible. These tablets are widely available in pharmacies and supermarkets. Folic acid is important for the development of your baby’s nervous system

Self referral form

Note: Questions marked by * are mandatory

*This is a mandatory field. First Name

*This is a mandatory field. Your surname (last name)

*This is a mandatory field. Previous Name

*This is a mandatory field. Date of Birth

DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

*This is a mandatory field. Address, including postcode

*This is a mandatory field. Current contact phone number

Is it ok to send you a text message?

Yes
No

Email Address

*This is a mandatory field. Do you need an interpreter?

Yes
No

If yes, what language

*This is a mandatory field. GP's name

*This is a mandatory field. GP practice address

*This is a mandatory field. Date of last period (first day)

DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

	Yes	No
Do you have diabetes?
Do you have epilepsy?
Do you have mental health problems?
Have you experienced a blood clot in your leg or lungs e.g. DVT
Have you experienced ectopic pregnancy
Do you have Renal (kidney) disease?
Do you have a respiratory (breathing) disease such as severe asthma?
Do you have heart disease?
Do you have a blood disorder?
Do you have an auto-immune disease?
Do you have high blood pressure?
Have you been pregnant before?

If yes how many times have you been pregnant?

How many children have you had?

Is there anything else you think we should know about you?