Maternity Self Referral form Home > Maternity Services > Maternity Self Referral form Important Message You can choose to birth your baby at home or in the hospital. When you meet your midwife you can discuss your choices further. Please leave this field empty. Where would you like to birth your baby? Please selectAiredaleBradfordHarrogateLeedsLancasterOther Please note: If you are planning to birth your baby at a hospital other than Airedale, you will also need to arrange a booking with that hospital. First Name (required) Last Name (required) Previous Last Name Date of birth (required) Address Contact telephone numbers Home phone number Mobile phone number Do you give consent for us to use these telephone numbers? Please selectYesNo Are you completing this on behalf of someone? Please selectYesNo Do you need an interpreter? Please selectYesNo If you selected yes, please tell us which language you prefer Do you give consent for us to share your details with health professionals involved in your care Please selectYesNo Are you happy for us to contact you by email? Please selectYesNo Email Address Ethnicity Please selectAsian or Asian British (Pakistan)Asian or Asian British (Bangladesh)Asian or Asian British (India)Asian or Asian British (Any other background)Black or British Black (Caribbean)Black or British Black (African)Black or British Black (Any other background)Mixed (White and Black Caribbean)Mixed (White and Black African)Mixed (White and Asian)White (British)White (Irish)White (Any other background)ChineseAny other backgroundPrefer not to say What GP surgery are you registered with? (required) Do you know the date of you last menstrual period (LMP)? Please selectYesNo Please can you confirm the date Have you been advised to take aspirin in pregnancy? Please selectYesNo Are you currently taking folic acid? Please selectYesNo – All pregnant women are advised to take 400mcg per day. Have you had a pregnancy end between 16 and 34 weeks gestation? Please selectYesNo Are you Diabetic or have you had Gestational diabetes in a previous pregnancy? Please selectYesNo Please provide further information in the below box Is there any additional information you think we should know at this point prior to your appointment with your Midwife?