Antenatal self-referral form

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About us

Refer yourself to our maternity care

We offer personalised care to women and pregnant people

We offer maternity care at Newham, The Royal London and Whipps Cross hospitals and the Barkantine and Barking birth centres.

Find out more about the choice in locations we offer you to have your baby

If you would like to choose to have your baby with us, please complete this form.

To translate this form, click on the flag icon at the bottom left corner of this page. However if you can, please provide your answers in English.

Please answer these questions as fully as possible so that we can book you in for the most appropriate care and place of birth.

The form will take around 10 minutes to complete.

If you need any help filling in this form, please call us on:

The Royal London Hospital: 020 7480 4885

Newham Hospital: 020 7363 9434

Whipps Cross Hospital: 020 8539 5522 extension 5055

Or you can download and complete a paper version of this form and bring it to any of our hospitals.

Your answers will be kept confidential.

Thank you for choosing Barts Health NHS Trust for your antenatal care.

About you

Note: Questions marked by * are mandatory

1. Title

*This is a mandatory field. 2. First name

*This is a mandatory field. 3. Last name

*This is a mandatory field. 4. Your date of birth

5. Gender

6. Your preferred pronouns

*This is a mandatory field. 7. Your address

8. NHS number (if known)

9. Hospital number (if known)

*This is a mandatory field. 10. Mobile phone

*This is a mandatory field. 11. Can we send Text/SMS messages to this phone number? This is to notify you of appointments.

Yes
No

*This is a mandatory field. 12. Email (if you do not have an email address please enter email@example.com)

*This is a mandatory field. 13. Can we email you about your appointment?

Yes
No

*This is a mandatory field. 14. Name of your GP practice (if you are not registered please write N/A)

*This is a mandatory field. 15. Address of your GP practice (if you are not registered please write N/A)

*This is a mandatory field. 16. Do you consent for us to request your medical history from your GP?

Yes
No

17. Do you identify with a religion? If yes, which one?

*This is a mandatory field. 18. Your ethnicity

Asian - Any Other Asian Background
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black - Any Other Black Background
Black or Black British - African
Black or Black British - Caribbean
Mixed - Any Other Mixed Background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
White - Any Other White Background
White - British
White - Irish
Other - Chinese
Other - Any Other Ethnic Group
Other - Not Stated

*This is a mandatory field. 19. Do you require an interpreter?

Yes
No

19a. If yes, which language?

*This is a mandatory field. 20. Do you have a physical disability?

Yes
No

*This is a mandatory field. 21. Do you have a learning disability?

Yes
No

*This is a mandatory field. 22. Do you have any communication needs, including hearing loss, visual impairment, dyslexia etc?

Yes
No

* Spam Guard: Does a dog tweet or bark?

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