Self referral form

Self referral form

Our Maternity Department offers you the option to self-refer to a midwife, which means that you will not need to go through your GP.

Simply fill in this form and a midwife will call you within seven working days to confirm a booking. Please ensure you fill in the form with all of your details, ensuring they are accurate before submitting your referral. If you have any questions, please contact the Maternity Helpline on 01733 677266.

Before your first appointment with the Midwife it would be helpful for you to read the booklet about the screening tests you will be offered. To read the booklet click here.

Please only phone 01733 673758 if you to attend the Emergency Gynaecology Assessment Unit. 

Indicates mandatory fields

Maternity self-referral form
Is English your first language?
Do you require an interpreter?