Maternity Self Referral Form

Welcome to Ashford and St Peter's Maternity Services

Please complete the form below giving us as much detail as possible about your self and any previous pregnancies and medical history that you have.


Please complete the form below and press 'print'.


Send the printed form to:

Antenatal Team Leader, Antenatal Clinic, Abbey Wing,
St Peter's Hospital, Guildford Road, Chertsey, Surrey KT16 0PZ


About You

  Family Name
Title (Mrs/Miss/Ms/Other)
  Date of Birth (dd/mm/yy)
NHS Number (10 digit number)
  Address, including your postcode
Home telephone number
Mobile telephone number
  Email address
Is English your first language?
Yes      No
  Where have you lived in the last 12 months?
UK      Outside of the UK
If not, what is?         
Do you require an interpreter?
Yes      No
  Can you show that you have the right to live here?
Yes      No
If Yes, which language?
  If you are a temporary resident in the UK, what is your permanent overseas address?
Name and Address of your registered GP
Your ethnicity:

White - Other

White and Black Caribbean
White and Black African
White and Asian
Mixed - Other

Asian or Asian British
Asian - Other
  Black or Black British
Black Caribbean
Black African
Black - Other

Other Ethnic Groups
Any other ethnic group
Not stated
Declined to answer


Current and Previous Pregnancies

Date of the first day of your last period (dd/mm/yy)
  Have you been pregnant before?
Yes      No
Details of previous pregnancies
  How many children do you have?
Have you used our Maternity Services before?
Yes      No


Your Health

Have you had any of the following (if yes please give details in the box below)
Heart Disease
Respiratory Disease
Sickle Cell / Thalassaemia
Kidney Disease
Liver Disease
Mental Illness
Thyroid Disease
Blood Clotting Disorder
Auto Immune Disease
Venous Thromboembolic Disease
  Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Yes      No
Are you taking any current medication?
Yes      No
If Yes, please give details, name and dose (if known):





What happens now?

The information you have provided will be reviewed and you will be contacted if we need any further details.

Please make sure that you have given us accurate contact details.

This referral will be processed and you will be sent an appointment for your 12-13 week ultrasound scan.


Meanwhile, please make a booking appointment with your local community midwife at your GP/Health Centre. This appointment will last approximately one hour, and during the appointment your midwife will take a detailed history, give you your maternity records and make future appointments with you. She will also answer any questions that you have about your pregnancy and on-going care. If you live out of our catchment area we will send you a booking appointment at St Peter's Hospital (please refer to our website for details of the catchment area).


Please note that following your booking appointment we will need to inform your GP and Health Visitor that you are pregnant so that they can support through your pregnancy and afterwards.