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? AiredaleBradfordHarrogateLeedsLancasterOther 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 Surname Previous surname Date of Birth Address Contact telephone numbers Home Mobile Do you give consent for us to use these telephone numbers? YesNo Are you completing this on behalf of someone? YesNo Do you need an interpreter? YesNo 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 YesNo Email address Are you happy for us to contact you by email? YesNo Ethnicity ---Asian 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 Can you confirm the date of the first day of your last menstrual period (LMP)? Have you been advised to take aspirin in pregnancy? YesNo Are you currently taking folic acid? YesNo – All pregnant women are advised to take 400mcg per day. Have you had a pregnancy end between 16 and 34 weeks gestation? YesNo What GP surgery are you registered with? Do you have diabetes? YesNo Is there any additional information you think we should know at this point prior to your appointment with your Midwife?
