Here's what to do next...

Need to consider your pregnancy options?

If you are pregnant and worried, you are not alone, we are here to help.

We are a holistic service based at Lancashire Teaching Hospitals for women stressed by an unwanted pregnancy who wish to discuss their options.

We pride ourselves on providing high quality care before, during and after treatment and make sure that you have enough support to help you to make the decision that is best for you.

We will support you every step of the way.

Please see Termination of Pregnancy (Abortion) Service | Lancashire Teaching Hospitals (lancsteachinghospitals.nhs.uk) for more information.

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. Your first booking appointment will be sent to you via the email address you provide.

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

Your booking appointment will between 9-11 weeks of pregnancy.

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

Folic Acid:

If you are not already taking a folic acid supplement you should start taking this straight away (400mcg/day). This should ideally be started three months before getting pregnant and continued for the first 12 weeks. This will help to protect against certain rare abnormalities.

Food hygiene and food-acquired infections:

We advise you only to drink pasteurised milk. Avoid cheeses such as camembert, brie and blue vein cheese. Avoid all pates, uncooked or undercooked ready prepared meals. https://www.nhs.uk/conditions/pregnancy-and-baby/healthy-pregnancy-diet/

Diet:

Having a healthy and nutritious diet in pregnant is really important as your baby relies on your to provide the right balance of nutrients to help them grow and develop.

Smoking:

Stopping smoking will help both you and your baby immediately. Harmful gases, such as carbon monoxide, and other damaging chemicals will clear from your body. Visit https://www.nhs.uk/conditions/pregnancy-and-baby/smoking-pregnant/ to find out the benefits to you and your baby when you stop smoking.

Alcohol:

It’s safer not to drink any alcohol if you’re pregnant, or planning to become pregnant, because it can damage your growing baby. By not drinking, you are protecting your baby and minimising the risks to their development and future health.

Medication:

Before taking any medicine when you're pregnant, including painkillers, check with your pharmacist, midwife or GP that it's suitable. https://www.nhs.uk/conditions/pregnancy-and-baby/medicines-in-pregnancy/

Exercise:

The more active and fit you are during pregnancy, the easier it will be for you to adapt to your changing shape and weight gain. It will also help you to cope with labour and get back into shape after the birth. https://www.nhs.uk/conditions/pregnancy-and-baby/pregnancy-exercise/

Self referral form

Note: Questions marked by * are mandatory

Birth Location Preference

*This is a mandatory field. Your option for birth:

Home
Chorley Birth Centre - free-standing midwife-led unit at Chorley and South Ribble Hospital
Preston Birth Centre - alongside midwife-led unit at Royal Preston Hospital
Sharoe Green Unit - consultant-led unit at Royal Preston Hospital
Undecided

About You

*This is a mandatory field. First Name

*This is a mandatory field. Your surname (family 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

We require your NHS number. If you don't know yours then please follow the link to get it and then continue filling in the form https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

*This is a mandatory field. Address Line 1

Address Line 2

*This is a mandatory field. Address Town

Address County

*This is a mandatory field. Address Post Code

*This is a mandatory field. Current contact phone number

Is it ok to send you a text message?

Yes
No

*This is a mandatory field. Email Address

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

Are you a smoker?

Yes
No

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?

Yes
No

*This is a mandatory field. Do you need an interpreter/British Sign Language?

Yes
No

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?

Yes
No

If yes, please provide details

GP Surgery Details

The name of your GP Doctor

*This is a mandatory field. Please select your GP Practice address from the list. If your GP is not in the list then please enter it manually below

Please Select An Option Adlington Medical Centre, 22-24 Babylon Lane, Anderton, Chorley, Lancashire, PR6 9NW-HawthornAvenham Surgery, Avenham Health Centre, Avenham Lane, Preston, Lancashire PR1 3RG-WillowBamber Bridge Health Centre, 29-31 School Lane, Bamber Bridge, Preston PR5 6QE-ChestnutBeeches Medical Centre, Liverpool Road, Longton, Preston, Lancashire, PR4 5AB-RowanBerry Lane Medical Centre, Berry Lane, Longridge, Preston, Lancashire, PR3 3JJ-CedarBriarwood Medical Centre, 514 Blackpool Road, Ashton-On-Ribble, Ashton Bank, Preston, Lancashire, PR2 1HY-RowanBroadway Surgery, Broadway, Fulwood, Preston, PR2 9TH-WillowBuckshaw Village Health Centre, Unity Place, Buckshaw Village, Chorley, PR7 7HZ-HawthornCentral Park Surgery, Balfour Street, Leyland, PR25 2TD-ChestnutChorley Health Centre, Collison Avenue, Chorley, PR7 2TH-HawthornClayton Brook Surgery, 59-60 Tunley Holme, Bamber Bridge, Clayton Brook, Preston, PR5 8ES-HawthornCoppull Medical Practice, Acreswood Surgery, 5 Acreswood Close, Coppull , Chorley, PR7 5EN-HawthornCottam Lane Surgery, Cottam Lane, Ashton, Preston, PR2 1JR-RowanCroston Village Surgery, Out Lane, Croston, Lancashire, PR26 9HJ-ChestnutDr Dawoud's Surgery, 652 Preston Road, Clayton-le-Woods, Chorley, Lancashire, PR6 7EH-HawthornEaves Lane Surgery, 311 Eaves Lane, Chorley, Lancashire, PR6 0DR-HawthornEccleston Village Surgery,The Health Centre, Eccleston, Chorley, Lancashire, PR7 5RA-ChestnutFishergate Hill Surgery, 50 Fishergate Hill, Preston, Lancshire, PR1 8DN-Eden/RowanGeoffrey Street Surgery, The Health Centre, Geoffrey Street, Preston, PR1 5NE-CedarGranville House Medical Centre, Granville Street, Adlington, Chorley, PR6 9PY-ChestnutGreat Eccleston Health Centre, Raikes Road, Great Eccleston, Preston, Lancashire, PR3 0ZA-OOAGuttridge Medical Centre, Deepdale Road, Preston, Lancashire, PR1 6LL-WillowIngol Health Centre, 87 Village Green Lane, Ingol, Preston, PR2 7DS-WillowIrwell Medical Centre/Irwell Mill/Rochdale Rd, Bacup, OL13 9NR-OOAIssa at Fulwood, 228 Garstang Road, Preston, PR2 9QB-WillowIssa Medical Centre, 73 St Gregory Road, Preston, Lancashire, PR1 6YA-WillowKingsfold Medical Centre, Woodcroft Close, Penwortham, Preston, Lancashire, PR1 9BX-RowanKirkham Health Centre, Moor Street, Kirkham, Preston, PR4 2DL-OOALane Ends Surgery, 200 Tulketh Brow, Ashton-on-Ribble, Preston, PR2 2JJ-RowanLeyland Surgery, Westfields, West Paddock, Leyland, PR25 1HR-ChestnutLibrary House Surgery, Avondale Road, Chorley, Lancashire, PR7 2AD-HawthornLongsands Medical Centre, Longsands Lane, Fulwood, Preston, Lancashire, PR2 9PS-CedarLongton Health Centre, Liverpool Road, Longton, Preston, PR4 5HA-RowanLostock Hall Medical Centre, Dardsley, Brownedge Road, Lostock Hall, Preston, PR5 5AD-Eden/ChestnutLostock Village Surgery, 1 William Street, Lostock Hall, Preston, Lancashire, PR5 5RZ-Eden/HawthornLytham Road Surgery, 2a Lytham Road, Fulwood, Preston, Lancashire, PR2 8JB-RowanMedicare Unit Surgery, 1 Croston Road, Lostock Hall, Preston, PR5 5RS-Eden/HawthornMoor Park Surgery, 49 Garstang Road, Preston, PR1 1LB-WillowMoss Side Medical Centre, 16 Moss Side Way, Leyland, Lancashire, PR26 7XL-ChestnutNew Longton Surgery, 2 Churchside, New Longton, Preston, Lancashire, PR4 4LU-RowanPark View Surgery, 23-24 Ribblesdale Place, Preston, PR1 3NA-Eden/WillowRegent House Surgery, 21 Regent Road, Chorley, PR7 2DH-HawthornRibble Village Health Centre, 202 Miller Road, Ribbleton, Preston, Lancashire, PR2 6NH-CedarRibbleton Medical Centre, 243 Ribbleton Avenue, Preston, Lancashire, PR2 6RD-CedarRiverside Medical Centre, 194 Victoria Road, Walton-Le-Dale, Preston, Lancashire, PR5 4AY-Eden/ChestnutRoslea Surgery, 51 Station Road, Bamber Bridge, Preston, PR5 6PE-ChestnutSandy Lane Surgery, Sandy Lane, Leyland, Lancashire, PR25 2EB-ChestnutSt Fillan's Medical Centre, 2 Liverpool Road, Penwortham, Preston, PR1 0AD -RowanSt. Marys Gate, Euxton, Chorley, PR7 6AH-ChestnutSt. Mary's Health Centre, Cop Lane, Penwortham, Preston, PR1 0SR-RowanStation Surgery, 8 Golden Hill Lane, Leyland, Lancashire, PR25 3NP-ChestnutStonebridge Surgery, Longridge, Preston, PR3 3AP-CedarTarleton Group Practice, Gorse Lane, Tarleton, Preston PR4 6UJ-OOAThe Chorley Surgery, 24-26 Gillibrand Street, Chorley, PR7 2EJ-HawthornThe Health Centre, Kelso Avenue, Thornton-Cleveleys, Lancashire, FY5 3LF-OOAThe Healthcare Centre, Flintoff Way, Deepdale, Preston, PR1 5AF -CedarThe New Hall Lane Practice, The Health Centre, Geoffrey Street, Preston, Lancashire, PR1 5NE-CedarThe Ryan Medical Centre, St Marys Road, Bamber Bridge, Preston, PR5 6JD-ChestnutThe Surgery Chorley, 32-34 St Thomas's Road, Chorley, Lancashire, PR7 1HR-HawthornThe Surgery, 63-65 Garstang Road, Preston, PR1 1LB-WillowWhitefield Health Care, Yarnspinners Health Care Centre, Yarnspinners Wharf, Carr Road, Nelson, BB9 7SR-OOAWhittle Surgery, 199 Preston Road, Whittle-Le-Woods, Chorley, PR6 7PS-HawthornWithnell Health Centre, Railway Road, Withnell, North Chorley, Lancashire, PR6 8UA-HawthornWorden Medical Centre, West Paddock, Leyland, Lancashire, PR25 1HR-ChestnutYewlands Drive Medical Centre, 20 Yewlands Drive, Leyland, PR25 2TN-ChestnutGP not in the list

*This is a mandatory field. GP practice address

Current Pregnancy Information

*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

Previous Pregnancy Information

*This is a mandatory field. Have you been pregnant before?

Yes
No

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

How many children have you had?

	Yes	No
Were any of your children born before 34 weeks gestation?
Have you had any miscarriages?
If yes, have you have experienced 3 or more miscarriages in a row?

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

Medical History

	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?

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. 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?

Yes
No

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. Please click submit to send the referral.