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Self-Registration Form for Maternity Care

Please complete all mandatory fields marked with *.  Failure to do so may slow down the processing of your registration.  Please share with us any information that you think is relevant to providing care for yourself or your baby.  The answers you provide will allow us to pass your registration to the correct Midwifery or Obstetric Team; therefore it is essential that you share as much information as possible.

Registrations can also be made by calling your local community midwives’ office on (Aylesbury) 01296 316120 or (High Wycombe) 01494 425172.

Please send all completed Self-Registration forms to bht.maternityreferrals@nhs.net – Thank You.

Please complete all fields marked with an astrix (*)

SELF REGISTRATION FORM


Are you completing this form on behalf of someone else?

If No, please continue to "mother’s information"

If Yes,

Does the mother need help from a translator?

Please be aware we do not advise family or friends to translate on behalf of pregnant women during an appointment.

MOTHER'S INFORMATION


Title:

PREVIOUS PREGNANCY INFORMATION


Any complications during previous pregnancies or births?*:

MEDICAL HISTORY


Do you take regular medication?*:

Have you ever experienced Diabetes?*:

Have you ever experienced Thyroid problems?*:

Have you ever suffered with any mental health concerns, such as depression, anxiety?*:

CURRENT PREGNANCY INFORMATION


Do you know the date of the 1st day of your last period?*:

Have you thought about where would you like to birth your baby?* :

SOCIAL HISTORY


Have you ever had support from a social or family support worker?*:

Do you currently drink more than 14 units of alcohol a week?*:

Do you smoke tobacco?*:

Have you ever taken recreational drugs?*:

Thank you for your enquiry, we will be in touch shortly.

If you wish to speak to a Community Midwife prior to your booking appointment, or if you have not been contacted within 10 working days, please contact your local office on (Aylesbury) 01296 316120 or (High Wycombe) 01494 425172/3   Monday – Friday 8:30 – 16:30.

In preparation for your booking appointment please download the “Mum & Baby” app, as this will form part of your care package.  The app can be downloaded to any Apple or Android device and is free of charge.