Kingston Maternity Self Referral

  • Kingston Maternity Self-Referral

  • DISCLAIMER

    Please note that we are using Jotform as part of our referral process. Further information can be found on our website.

    Further information can be found on the privacy notice pages on our website.

     

     

  • Congratulations on your pregnancy and thank you for choosing to book your care with Kingston Maternity department.
    It should take about 5-10 minutes to complete the self-referral form.

    The fields marked with '*' are compulsory, however, it is helpful to provide as much detail as possible to enable us to provide you with the best possible care, which takes into account your medical and pregnancy needs.

    Please note, on completion of this self-referral we will notify your GP of your pregnancy and your intention to receive care with Kingston Maternity unit.

    We will process your form as quickly as possible, but this can take up to 14 days, after which you should receive your booking and scan appointment dates. If you have not heard from us by then, or you have any questions about your referral, please contact the Antenatal Admin office on 020 8934 2290.

     

  • Personal Information

  • Date of Birth*
     - -
  • Is the gender you identify with the same as your sex registered at birth?
  • Do you speak English?*
  • Would you like an interpreter at your appointments?
  • Format: 0000 000 0000.

  • GP Details and Current Pregnancy Information

  • Do you know the date of your last period?*
  • What is the date of first day of your last period?
     - -
  • Is this pregnancy IVF?*
  • What is the Estimated date of birth?
     - -
  • What is the egg collection date?
     - -
  • What is the egg transfer date?
     - -
  • Is this a donor egg?*
  • Is this donor sperm?*
  • Have you had a scan during this pregnancy?*
  • Are you expecting more than one baby?

  • Medical Information

  • Are you currently taking any medication?*
  • Have you ever been diagnosed with any of the following (please select any that are applicable to you)*
  • Are you a carrier (trait) of Sickle cell?*
  • Are you a carrier (trait) of Thalassaemia?*
  • Is the biological father/sperm donor of your baby a carrier (trait) of Sickle cell?*
  • Is the biological father/sperm donor of your baby a carrier (trait) of Thalassaemia?*
  • Do you require help with: (please select as appropriate)*
  • Do you, or have you ever, suffered from anxiety, depression or any other mental health condition?*
  • Are you under the care of a psychiatrist or mental health team?*
  • Are you or your family supported by a social worker?*

  • Previous Pregnancy Information

  • Have you had 3 or more miscarriages or an ectopic pregnancy in the past?*
  • Have you had a previous stillbirth?*
  • Have you had  a baby with a chromosomal or genetic disorder? (e.g. Downs, Pataus or Edwards syndrome)*
  • Have you had a caesarean birth before?*
  • Are you interested in receiving information about having your baby at home?
  • Would you like any information about our Birth Centre (the midwife-led unit)?
  • Should be Empty: