Maternity Self Referral form - Airedale NHS Foundation Trust

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

Due to essential ongoing maintenance work on the Labour Ward roof, from 23/4/26 the Maternity Assessment Centre (MAC) will be located in Antenatal Clinic between the hours of 07:30 and 19:30. Out of hours the MAC service will remain on Labour Ward. The contact number remains unchanged.

During the day, MAC can be accessed via the Antenatal Clinic entrance or the Labour Ward entrance. Additional signage will be in place by the Labour Ward entrance.

There will be no change to any services provided on Labour Ward.

Maternity Self Referral with Airedale 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 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.

Which trust do you wish to birth at?

FIRST NAME*

SURNAME*

PREVIOUS SURNAME

DATE OF BIRTH*

NHS number*

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

Ethnicity*

If other please specify

Are you completing this form on behalf of someone?

YesNo

Your name and contact number
Relationship to the person you are completing this form for

Do you need an interpreter?*

YesNo

If an interpreter is required, what language?

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

YesNo

Please provide details relating to your access requirements

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

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

I do not consent

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/2022)

Please provide further details

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

Do you have any Allergies*

GP's Name*

GP Telephone Number*

GP Practice Name*

GP Address*

Previous Pregnancy	Answers
Is this your first pregnancy?	YesNo

Previous Pregnancy History	Answers
Have you previously had a baby at Airedale?	YesNo
Have you had a caesarean section?	YesNo
Have you had a vaginal birth since your caesarean section?	YesNo
Have you had a baby born before 34 weeks of pregnancy?	YesNo
How many pregnancies have you had?
How many children do you have?
Have you had a previous pregnancy loss after 12 weeks?	YesNo

Previous Medical History	Answers
Do you have diabetes?	YesNo
Do you have breathing problems such as severe asthma?	YesNo
Do you have epilepsy?	YesNo
Have you had an ectopic pregnancy?	YesNo
Do you have high blood pressure?	YesNo
Do you have heart disease?	YesNo
Do you have kidney disease?	YesNo
Do you have mental health problems?	YesNo
Have you had a blood clot in your legs or lungs, eg. DVT?	YesNo
Do you have a blood disorder, eg. Sickle cell or thalassaemia?	YesNo
Do you have any other conditions you need to see a GP or consultant about?	YesNo
Do you take any regular medication?	YesNo
Is there anything else you think we need to know about you?	YesNo

Please provide brief details on what we may need to know

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

Please give brief details on social services involvement

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