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Maternity Self Referral form

Congratulations on your pregnancy

By completing this form, you are arranging your maternity care at Airedale NHS Foundation Trust. 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 mandatory fields.

If you have any difficulties understanding or completing this form, please contact the Single Point of Access team on 01535292411 or 01535292412

Home > Maternity Services > Maternity Self Referral form

    Maternity Self Referral with Airedale NHS Foundation Trust's Maternity services

    Fields marked with * are required

    If you wish to birth your baby in the Airedale NHS Foundation Trust please continue to complete our online self-referral form.

    If you wish to birth your baby in Bradford Women's and Newborn unit please fill their self-referral form. All your care throughout pregnancy, birth and after birth will be provided by the Bradford Women's and Newborn unit.

    You do NOT need to complete this 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 the Airedale 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.



    Find your NHS number (This link
    provides help for finding your NHS number)

    Are you completing this form on behalf of someone?


    Do you need an interpreter?*

    Do you have any access requirements we need to be aware of *

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

    We will share your details with healthcare professionals involved in your care, if you do not consent to this, please tick this box

    Have you had a positive pregnancy test?*

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


    Previous Pregnancy

    Answers

    Is this your first pregnancy?

    Previous Pregnancy History

    Answers

    Have you previously had a baby at Airedale?

    Have you had a caesarean section?

    Have you had a vaginal birth since your caesarean section?

    Have you had a baby born before 34 weeks of pregnancy?

    How many pregnancies have you had?

    How many children do you have?

    Have you had a previous pregnancy loss after 12 weeks?


    Previous Medical History

    Answers

    Do you have diabetes?

    Do you have breathing problems such as severe
    asthma?

    Do you have epilepsy?

    Have you had an ectopic pregnancy?

    Do you have high blood pressure?

    Do you have heart disease?

    Do you have kidney disease?

    Do you have mental health problems?

    Have you had a blood clot in your legs or lungs, eg. DVT?

    Do you have a blood disorder, eg. Sickle cell or thalassaemia?

    Do you have any other conditions you need to see a GP or consultant about?

    Do you take any regular medication?

    Is there anything else you think we need to know about you?

    Social Services

    Answers

    Do you currently have or have you previously had any involvement with Social Services?

    Contact Preferences

    Can we send letters to your address?


    A confirmation email will be sent to this address