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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.

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

If you have any difficulty completing the form below or you get an error message, please download and complete this self-referral form and return by email to:

Please only complete the self-referral form if you want to give birth in the Royal-Jubilee Maternity Hospital in Belfast.

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

  • 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.