Just found out you're pregnant?

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Just found out you're pregnant?

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.

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

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

*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)

	Yes	No
Are you a smoker?
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?

*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)

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?)

Just found out you're pregnant?

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Just found out you're pregnant?

Just found out you're pregnant?

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

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