Refer yourself to our maternity care

pregnant lady using phone

We offer personalised care to women and pregnant people

We offer maternity care at Newham, The Royal London and Whipps Cross hospitals and the Barkantine and Barking birth centres.

Find out more about the choice in locations we offer you to have your baby

If you would like to choose to have your baby with us, please complete this form.

To translate this form, click on the flag icon at the bottom left corner of this page. However if you can, please provide your answers in English.

Please answer these questions as fully as possible so that we can book you in for the most appropriate care and place of birth.

The form will take around 10 minutes to complete.

If you need any help filling in this form, please call us on:

The Royal London Hospital: 020 7480 4885 

Newham Hospital: 020 7363 9434

Whipps Cross Hospital: 020 7767 3348

Or you can download and complete a paper version of this form and bring it to any of our hospitals.

Your answers will be kept confidential.

Thank you for choosing Barts Health NHS Trust for your antenatal care.

Section 1. About you

Note: Questions marked by * are mandatory

This form helps us understand you better so we can provide safe, personalised care during your pregnancy. Some questions may feel personal, but your answers are confidential and only seen by staff involved in your care. You'll also have a chance to speak privately with a midwife at your first appointment.

Note:  “You” or “your” refers to the woman or birthing person who is currently pregnant.

 

*This is a mandatory field.

1. Are you completing this form for:
*This is a mandatory field.

6. Your preferred pronouns

12. I do not have an NHS number

16. Are you currently a UK resident?

17. If you answered no to question 17, how long have you lived in the UK? We ask this to
understand who is entitled to free hospital care or who might be charged under the
government's regulations.  This does not affect your right to receive maternity care.  

18. If you answered no to question 16, what is your main reason for stay:

20. Do you have an EHIC/GHIC, S1/S2, or other reciprocal healthcare cover? This helps us bill the
correct organisation where applicable.  

21. Which best describes your current status? This helps us apply the correct NHS rules and
connect you to any support you're entitled to.  Your care will not be delayed while we check
this.
*This is a mandatory field.

22. Are you a member of the Armed Forces Community?
*This is a mandatory field.

23. Are you registered with a General Practice/Family Doctor? 
*This is a mandatory field.

25. Do you have a preferred hospital or place of birth? 

26. Are you interested in a home birth?
*This is a mandatory field.

27. Have you had care for this pregnancy from a doctor or midwife at another hospital or in another country?

Ethnicity, language and additional needs of the woman/birthing person

Why do we ask about your ethnicity during pregnancy? Some health conditions and pregnancy risks can affect ethnic groups differently.

*This is a mandatory field.

29. What is your ethnic background?
*This is a mandatory field.

31. Do you need an interpreter or British Sign Language (BSL) support?  We want to make sure that we can communicate with you clearly.  Friends and family members cannot act as interpreters.  If you would like an interpreter, we can provide this service at no cost to you. 

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