King's College Hospital antenatal self-referral

You can choose to refer yourself directly to the antenatal services at King’s College Hospital, rather than via your GP. Please complete this form, giving as much detail as possible so that we can ensure the best pathway for your maternity care. The information you provide will be placed in your medical records and only accessed by staff involved in your care.

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
Thalassemia/sickle cell
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