Maternity Services

Birth Location Preferences

Your option for birth* HomeChorley Birth Centre - free-standing midwife-led unit at Chorley and South Ribble HospitalPreston Birth Centre - alongside midwife-led unit at Royal Preston HospitalSharoe Green Unit - consultant-led unit at Royal Preston HospitalUndecided

About You

First Name*

Your Surname (family name)*

Previous Name*

Date of Birth*

Address Line 1*

Address Line 2

Address Town*

Address County

Address Post Code*

Current contact phone number*

Is it ok to send you a text message? YesNo

Email Address*

Alternative email address (in case the above email address doesn't work)

Are you a smoker? YesNo

The risks of smoking during pregnancy are serious. To give your baby the best start in life we will refer you for support in stopping. Respond “No” if you do not agree for your details to be shared with the QuitSquad? YesNo

Do you need an interpreter/British Sign Language?* YesNo

If yes, what language

Do you have any mobility, sight, hearing or other particular needs that we should be aware of to help prepare for your appointment? YesNo

If yes, please provide details

GP Surgery Details

The name of your GP Doctor*

GP practice address*

Current Pregnancy Information

Date of last period (first day)*

Previous Pregnancy Information

Have you been pregnant before?* YesNo

If yes how many times have you been pregnant? (Including this pregnancy)

How many children have you had?

Were any of your children born before 34 weeks gestation? YesNo

Have you had any miscarriages? YesNo

If yes, have you have experienced 3 or more miscarriages in a row? YesNo

Is there anything else you think we should know about your previous pregnancies?

Medical History

Do you have diabetes? YesNo

Do you have epilepsy? YesNo

Do you have mental health problems? YesNo

Have you experienced a blood clot in your leg or lungs e.g. DVT YesNo

Have you experienced ectopic pregnancy YesNo

Do you have Renal (kidney) disease? YesNo

Do you have a respiratory (breathing) disease such as severe asthma? YesNo

Do you have heart disease? YesNo

Do you have a blood disorder? YesNo

Do you have an auto-immune disease? YesNo

Do you have high blood pressure? YesNo

Do you have any other health conditions that we should know about you?

Is there anything else that you think we should know about you? (e.g. had care at another trust and want to transfer to LTHTr? Availability? Information given to you after a previous pregnancy regarding future pregnancies?)

BadgerNet and Maternity Notes

This is a mandatory field. Badger Notes: We use paperless notes with CleverMed's Badger Notes App through BadgerNet , this allows you to access your maternity records via your smart phone, tablet or PC. BadgerNet will send occasional emails, text message and push notifications (e.g. appointment reminders) through the maternity app. Please see here (https://www.lancsteachinghospitals.nhs.uk/badgernet) for more information about privacy and your data usage. Are you are happy with the information above regarding the maternity notes portal, to have emails, texts and push notifications from the app and consent to use the Maternity Notes app?* YesNo

Next steps: After you have submitted your referral, we will aim to have it processed within TWO WEEKS. You will receive an NHS email from us with your activation phrase and an email from CleverMed to sign up to Badger Notes (it will say you will get an activation phrase from your midwife - please ignore this, it will be sent in the previously mentioned NHS email). Your booking appointment will be arranged by your midwife before you are 13 weeks of pregnancy and will appear on the app.

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