Princess Royal University Hospital antenatal self-referral form

You can choose to refer yourself directly to the antenatal services at Princess Royal University 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.

Your appointment will be emailed to you. PLEASE ENSURE YOU CHECK YOUR JUNK EMAIL FOLDER.

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
Your clinical details

Regarding any previous pregnancies, how many of the following have you had:

Regarding previous births, how many times have you given birth by:

Do you have any of the following health problems, if "yes" please give details:

Type 1 Diabetes
Type 2 Diabetes
Impaired Glucose Tolerance
Gestational Diabetes, now or in the past
High blood pressure
Mental health
Thalassemia/sickle cell
Have you have transferred your care from another maternity unit? If so please give details
Have you given birth before at the PRUH or King’s College Hospital?
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?
Your mental wellbeing

In the past month have you:

Felt down, depressed or hopeless?
Felt little interest or pleasure in doing things?
Felt nervous, anxious or on edge?
Not been able to stop or control worrying?
If you have answered yes to any questions in this section, is this something you need or want help with?
Is there anything else you would like to add about your mental wellbeing?

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
Maternity Notes - your online pregnancy records

You can choose to see your notes via an electronic system called Maternity Notes. You can do this through a smartphone app or a website during your pregnancy. The system includes:

  • details of upcoming appointments
  • space to write your birth plan
  • links to national resources and websites
  • links to King’s patient information leaflets
  • feedback forms

How and why Maternity Notes uses your information

If you would like to see your pregnancy records online, confirm below that you consent to this and provide the email and mobile phone number requested. These allow us to set up secure three-step verification, which is important because it ensures your personal health records can only be accessed by you.

Your email address will only be used by the hospital to contact you regarding this pregnancy. It will be shared with Clevermed Ltd, the company that provides the Maternity Notes system. It will not be shared with any other external organisations. For further information about how your data will be used and stored, go to:

Check your email

If you consent to use Maternity Notes, please check your email regularly, as this is how we will send you details of your first appointment with a midwife. You may need to check your junk email folder or add to your contacts in advance.

The email we send you will include links to download the Maternity Notes app or login to the website. We encourage you to enter some of your personal information into Maternity Notes before your booking appointment.

Give consent to use Maternity Notes

If consent given, please provide:

  • an email address, which only you can access
  • your personal mobile telephone number (you will receive a verification text message to this number when you first set up your account. This number will also be used if you forget your password)
Use email address already provided
Use contact number already provided