Here's what to do next...

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 (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 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

*This is a mandatory field. GP's name

*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 past 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. Maternity Notes: We use paperless notes with CleverMed's Maternity 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 Maternity Notes (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