Title: Antenatal self referral form
Author: rcollin1
Last saved by: Helen Tewolde
Company: UCL Hospitals NHS Foundation Trust

North Central London Maternity Services Referral Form

DATE OF REFERRAL:
Please the corresponding box for the hospital the referral is being made to:

Barnet & Chase Farm
Fax: 020 8216 5136
Tel:  020 8216 5137
antenatal@bcf.nhs.uk

Edgware Birth Centre
Fax: 020 8732 6773
Tel:  020 8732 6777/6669
birthcentre.ech@bcf.nhs.uk

North Middlesex
Fax: 020 8887 2934
Tel:  020 8887 2000 # 3055

Urgent: Yes  / No
Specify:

Royal Free
Fax: 020 7830 2752
Tel:  020 7794  0500 # 36169

UCLH
Fax: 020 3447 9400
Tel:  020 3447 9754
antenatalclinic@uclh.nhs.uk

Whittington
Fax: 020 7288 5576    
Tel: 020 7288 5586
Whh-tr.maternityreferrals@nhs.net

Office Use Only
 Urgent	  Routine
 High Risk   Low Risk

PLEASE ANSWER ALL QUESTIONS IN BLOCK CAPITALS

Surname:Surname 

First Name:Calling Name 

All previous surnames:Previous Surname

Title: Mrs/ Miss/ Ms/ Other

Date of Birth: Date of Birth                     Age:Age 

NHS number: NHS Number

Address:Home Full Address (stacked) 

Post Code:Home Address Postcode 

Preferred contact tel no:Patient Mobile Telephone

Details of GP:  (name, address, telephone and fax)

Registered GP Full Address (stacked)

Ethnicity:  Ethnic Origin

Interpreter required:   yes / no   
Language:Main Language

Name and details of referrer if not GP:Current User | Signature:
LMP: | EDD: | Gestation (Wks):

Past Obstetric history:      

Past Gynaecological History:     

Past Medical and Surgical History:      

Significant psychological history:

Current medication:     

Allergies:     

Significant family history:     

Social concerns and details of social worker if applicable:

Other comments  (include letter if needed):
MEDICAL RISK ASSESSMENTS
Auscultation Heart: | Auscultation Lungs:
Weight (Kg):Weight | Height (cm):Height | BMI:BMI
Alcohol History:Alcohol Consumption | Smoking history:Smoking
BP:Blood Pressure | Urine  (protein and glucose):  Urine Blood

The patient should be offered an appointment at the latest by 12/40 or within 2 weeks, if they are referred after 12/40.