Self-referral form

Our aim is to ensure you receive maternity care in the right place, with the right people looking after you and your baby. We would advise you to read the Now you are pregnant leaflet for birth choices.

We will be delighted if you choose the Maternity Hospital or Midwife-Led Unit for your care.

You can now self-refer to Belfast Trust maternity services as soon as you have a positive pregnancy test.

Please complete the self-referral form below

Maternity Referral Form

  • Your details

  • Medical information

  • Previous pregnancies

    Regarding any previous pregnancies, how many of the following have you had:
  • Previous births

    Regarding previous births, how many times have you delivered by
  • Additional info

  • If you are taking prescribed medication, please contact your GP as soon as possible.