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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

Self-referral form for Royal-Jubilee Maternity Service at Belfast Trust

Your details
Name*
First Last
Maiden name / Previous surname
Date of birth*
Address*
Street Address Address Line 2 City ZIP / Postal Code
Preferred contact number
Email
Nationality
Spoken language
Interpreter needed?
- Yes
- No
Medical information
GP Name and Address
Street Address Address Line 2 City ZIP / Postal Code
Weight
Height
BMI (if known)
Do you smoke?
- Yes
- No
If you smoke, how many?
First day of last menstrual period or best guess
Previous pregnancies
Regarding any previous pregnancies, how many of the following have you had:
Pregnancies
Live children
Have you had any babies born before 37 weeks
Ectopic pregnancies
Miscarriages
Still birth / Neonatal death
Please give details of any problems in previous pregnancies:
Previous births
Regarding previous births, how many times have you delivered by
Normal vaginal birth
Ventouse (suction)
Caesarean section
Forceps
Additional info
Details of any medical conditions, operations or allergies. Please include details of any current medications
If you are taking prescribed medication, please contact your GP as soon as possible.
I would like to consider giving birth in the Midwife-Led Unit in the Mater
- Yes
- No
Please add any other information you feel is relevant to your ongoing care

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Contents

Self-referral form

Self-referral form for Royal-Jubilee Maternity Service at Belfast Trust

Your details

Medical information

Previous pregnancies

Previous births

Additional info