King's College Hospital antenatal self-referral

PLEASE DO NOT USE THIS SELF-REFERRAL FORM AS WE WILL NOT RECEIVE YOUR REFERRAL. PLEASE INSTEAD PLEASE DOWNLOAD AND FILL OUT THE KCH ANTENATAL SELF-REFERRAL FORM DOCUMENT FOUND HERE AND EMAIL TO kch-tr.antenatalreferral@nhs.net, THANK YOU.

Your details
Do you have any of the following special requirements? If "yes" please give details:
Need an interpreter
Learning disabilities
Hearing problems
Sight problems
Details about your GP
Information about your current pregnancy
Regarding any previous pregnancies, how many of the following have you had:
Regarding previous births, how many times have you delivered by:
Do you have any of the following health problems, if "yes" please give details:
Breathing
Diabetes
Heart
High blood pressure
Kidney
Liver
Mental health
Neurological
Do you or the father of the baby have sickle cell disease or trait?
Do you or the father of the baby have thalassemia or thalassemia trait?
Other
Are any of the following relevant to you, if "yes" please give details:
Substance abuse (including your partner)
Violence/domestic abuse
Safeguarding/known to social services
Asylum seeker/refugee
Smoker