Referral to Bradford Maternity Services – Bradford Teaching Hospitals NHS Foundation Trust

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.

Maternity Self Referral with Bradford Teaching Hospitals NHS Foundation Trust's Maternity services.

Fields marked with * are required

Where would you like to birth your baby?*

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.

You MUST also refer directly to Calderdale, please visit Calderdale and Huddersfield NHS trust's webpage.

Alongside this form, please self-refer to Leeds Teaching Hospital NHS Trust via www.mypregnancynotes.com

This referral form is for homebirth in Bradford area only

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.

Which trust do you wish to birth at?

FIRST NAME*

SURNAME*

PREVIOUS SURNAME

DATE OF BIRTH*
(e.g. 04/Mar/1989)

ETHNICITY*

If other please specify

Are you completing this form on behalf of someone?
YesNo

Name and Telephone number
Relationship

Do you need an interpreter?*
YesNo

What language?

House/Flat Number*

1st Line of Address*

Post Code*

Previous address (if known)

Home Phone Number.

Mobile Number*

Do you give your consent for us to use these telephone numbers?*
YesNo

Do you give consent for us to share your details with health professionals involved in your care*
YesNo

Have you had a positive pregnancy test?*
YesNo

Do you know when your last menstrual period (LMP) was*
YesNo

First day of last menstrual period (LMP)

(e.g. 04/Mar/1989)

Please provide further details

Would you consider birthing your baby at home or would like more information about this?
YesNo

Do you have any Allergies*

GP's Name*

GP Telephone Number*

GP Practice Name*

GP Address*

Previous Pregnancy History

	Yes	No
Is this your first pregnancy?*	Yes	No
Have you had a caesarean section?	Yes	No
Have you had a vaginal birth since your caesarean section?	Yes	No
Have you had a baby born before 34 weeks of pregnancy?	Yes	No
Have you had a previous pregnancy loss after 12 weeks?	Yes	No


How many pregnancies have you had?
How many children do you have?

Previous Medical History

	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

Is there anything else you think we need to know about you?	Yes	No

Contact Preferences

What is your preferred method of contact?*

Can we send letters to your address?
YesNo

Please provide a correspondence address

Email Address

A confirmation email will be sent to this address if provided