Congratulations on your pregnancy.
By completing this form you are arranging your maternity care at Bradford Women’s and Newborn Unit. You can choose to birth your baby at home or in the hospital, when you meet your midwife you can discuss your choices further.
To avoid a delay in your care please make sure you complete all fields.
If you have any difficulties understanding or completing this form please contact your GP surgery to make a referral for you.

Please use this form to make your Maternity Self Referral with Bradford Teaching Hospitals NHS Foundation Trust's Maternity services.

Fields marked with * are required

Birthing Location*

If you wish to birth your baby in Airedale NHS Foundation Trust please call the single point of access to self-refer on 01535 292411. All your care throughout pregnancy, birth and after birth will be provided by Airedale maternity services.

You do NOT need to complete this form.

If you wish to birth your baby in Bradford Women’s and Newborn unit please continue to complete our online self-referral form.

If you wish to birth your baby in Calderdale and Huddersfield NHS trust, but live in Bradford and wish to have pregnancy and after birth care from Bradford Midwives please visit Calderdale and Huddersfield NHS trust's webpage to self refer to them and continue to complete the Bradford self-referral form.

If you wish to birth your baby in Leeds Teaching Hospitals NHS Trust , but live in Bradford and wish to have pregnancy and after birth care from Bradford midwives please ask your GP to refer you to them and continue to complete the self-referral form.

If you wish to birth your baby in any other hospital , but live in Bradford and wish to have pregnancy and after birth care from Bradford midwives please ask your GP to refer you to them and continue to complete the self-referral form.



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YesNo






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YesNo


Previous Pregnancy History


Yes / No
Yes No

Previous Medical History

Do you have or have you had any of the following?

Yes No
Do you have diabetes? Yes No
Do you have breathing problems such as severe asthma? Yes No
Do you have epilepsy? Yes No
Have you had an ectopic pregnancy? Yes No
Do you have high blood pressure? Yes No
Do you have heart disease? Yes No
Do you have kidney disease? Yes No
Do you have mental health problems? Yes No
Have you had a blood clot in your legs or lungs, eg. DVT? Yes No
Do you have a blood disorder, eg. Sickle cell or thalassaemia? Yes No
Do you currently have or have you previously had any involvement with Social Services? Yes No

Contact Preferences



YesNo

Please provide correspondence address

Involving you to improve our services

This online form is a new way to get in touch with Bradford Maternity Services.

We value your feedback and want to know what you think about this self-referral form.

Help us to improve our service by answering 5 short questions here.

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