Southampton maternity self-referral

I'm pregnant - what happens next?

If you're at least six weeks pregnant, you can refer yourself directly to our maternity service using this form. Please have your NHS number available to complete this referral - if you don't know this, you can get it from your GP surgery. Please provide as much information as possible, as this will help us to provide you with the most appropriate care.

Once your form has been processed, the information will only be shared with the people caring for you. You'll be contacted by our triage midwife to discuss your referral and let you know the next steps. We aim to do a full booking appointment in week 10 or 11 of your pregnancy. We'll also advise your GP that you're pregnant, as we're obliged to let them know we're caring for you as it may affect other health conditions they are helping you with.

We will send you a confirmation email to let you know we have received your form (please make sure you enter you email address correctly in the form below). Please allow up to 10 working days for us to process your booking. If you don't hear from us, please call our maternity admin team on 023 8120 8714.

If you have any queries or would prefer not to use this form, please contact our triage midwives on 023 8120 8513 or 07468 755695, Monday to Friday between 9am and 5pm.

For information on how we use your personal data and your rights, please read our leaflet. Information submitted through this form is held and processed in accordance with our data protection policies. To read more about how we process the information on this form, please visit our privacy notice page here.

Please complete this form as fully as you can. When your form is submitted, you will see a message confirming this and a page of information that we recommend you read. If you do not see this message, your form has not been sent. Please make sure that you have filled in all the required information in section 1, and ticked the box giving consent for your information to be shared.

If you would like to keep a copy of this form, please print or save it to your computer before pressing submit.

  • Are you completing this form as a pregnant person or as a health professional?
  • 1. Pregnant person's details
  • Is English your first language?
  • Do you need an interpreter present at your booking appointment?
  • 2. GP's details
  • 3. Current pregnancy
  • Have you been taking folic acid?
  • We recommend that you take 400mcg a day of folic acid, or 5mg prescribed by your GP if you: have a family history of neural tube defects (spina bifida)/ have epilepsy/ have diabetes/ have coeliac disease/ have a body mass index (BMI) over 30. You can calculate your BMI online www.nhs.uk/livewell/loseweight/pages/bodymassindex.aspx
  • Have you been taking vitamin D? (You should be taking 10 mcg a day of vitamin D)
  • 4. Previous pregnancies and births
  • 5. History
  • Do you or the father of your baby have or carry sickle cell or thalassaemia?
  • Do you have any medical conditions, such as a heart or lung condition, epilepsy or diabetes?
  • Are you taking any regular medication (including prescribed or bought over the counter)?
  • If you are taking any regular or prescribed medication please check with your GP that it is safe to take during your pregnancy. Some medication and doses may need to be altered whilst you are pregnant to be safe for you and your baby. Please do not stop taking any prescribed medication before checking with your GP first.
  • 6. About you
    Please answer these questions honestly so we can plan and tailor your care to you and your baby. If you don't feel comfortable giving information here, you can speak to a midwife instead.
  • It is important for us to know your body mass index (BMI). You can calculate your BMI online www.nhs.uk/livewell/loseweight/pages/bodymassindex.aspx
  • Do you have any problems with:
  • Do you smoke?
  • Have you ever been affected by domestic abuse?
  • Have you or your partner ever used recreational drugs?
  • Have you or your partner ever misused alcohol?
  • Have social services ever been involved with you or your children?
  • Do you have any historic, recent or ongoing mental health concerns?
  • By providing this information, I give my consent for it be shared with the people involved with my care.

When your form is submitted, you will see a message confirming this and a page of information that we recommend you read. If you do not see a confirmation message, your form has not been sent. Please make sure that you have filled in all the required information in section 1, and ticked the box giving consent for your information to be shared.

If you have any queries or would prefer not to use this form, please contact our triage midwives on 023 8120 8513 or 07468 755695.