Skip to content

Search site

East Sussex Healthcare

Your care
Our locations
Our services
About us
Working for us
Research

Home > Our services > Maternity > Maternity self referral

In this section

Maternity

Maternity self referral

Book to have your baby with East Sussex Healthcare NHS Trust's Maternity service

In this section

Maternity

Please use our form below to book to have your baby with our Maternity service.

Once you have completed the form, you will be sent an email confirming we have received your referal. This will be sent to the email address you entered on the form.

My choices for Pregnancy, Birth and Beyond

This booklet will help you make informed choices around your care and you can use it to record your thoughts and feelings during your pregnancy journey, or use it to spark conversations with your Midwife and Maternity team. It does not form part of your medical record.

We use an electronic maternity notes system called ‘BadgerNet’ – see more information.

Useful information

Information on vitamins, supplements and nutrition in pregnancy

Information on Screening tests available in pregnancy

Screening Tests for you and your baby

Sussex Local Maternity and Neonatal System

Work out your BMI – required for this form.

Make your maternity self referral with us

Your details
Name*

First

Middle

Last
Maiden name/previous surname
What is your Partnership status*
Address*

Address

Town/City

County

Postcode
Preferred contact number*
Email*

Enter Email

Confirm Email
Date of Birth*

Day

Month

Year
NHS Number (if known)
Do you follow a religion?*
- Yes
- No
Please state what religion*
Ethnic Origin*
Country of birth
Are you new to this area?*
- Yes
- No
For this pregnancy, have you received maternity care at a different hospital?*
- Yes
- No
If yes, please state where*
Do you have any of the following special requirements? If "yes" please give details:
Need an interpreter*
- Yes
- No
Please give details*
Learning disabilities*
- Yes
- No
Please give details*
Hearing problems*
- Yes
- No
Please give details*
Sight problems*
- Yes
- No
Please give details*
Details about your GP
GP name*
Address

Street Address

City

ZIP / Postal Code
Phone number
Information about your current pregnancy
First day of last menstrual period

If you are unsure please add question marks
Date you think your baby is due

Day

Month

Year
Where would you like to have your baby?*
Your height in metres (e.g. 1.45)*
Your weight in kilos (e.g. 64)*
Body Mass Index*

If your BMI is over 30 at booking it is very important that your GP prescribes 5mg Folic Acid for the first 12 weeks - Work out your BMI (opens in new window).
Pregnant people with a BMI 30 and above require the higher dose of Folic Acid 5mg within the first 12 weeks of pregnancy. This needs to be prescribed by your GP and cannot be bought over the counter.

Please review the following guidance - Healthy eating and vitamin supplements in pregnancy patient information leaflet

Any questions please call: 0300 131 4500 Ext: 770329 or contact: maternity.publichealth@nhs.net
Is this pregnancy a result of any Infertility treatment?*
- Yes
- No
Regarding any previous pregnancies, how many of the following have you had:
Pregnancies
Live children
Have you had any babies born before 37 weeks
Ectopic pregnancies
Miscarriages and terminations
Still births
Neo-natal deaths
Have you had a pregnancy complicated with gestational diabetes (GDM)?*
- Yes
- No
Please give details*
Have you lost a baby before birth*
- Yes
- No
Please give details*
Has a previous pregnancy been affected by Down’s Syndrome (T21)?*
- Yes
- No
Has a previous pregnancy been affected by Edward’s syndrome (T18)?*
- Yes
- No
Has a previous pregnancy been affected by Patau’s syndrome (T13)?*
- Yes
- No
Regarding previous births, how many times have you delivered by
Normal vaginal birth
Caesarean section
Ventouse (suction)
Forceps
Do you have any of the following health problems, if "yes" please give details
Breathing*
- Yes
- No
Please give details*
Diabetes*
- Yes
- No
Please give details*
Heart*
- Yes
- No
Please give details*
High blood pressure*
- Yes
- No
Please give details*
Kidney*
- Yes
- No
Please give details*
Liver*
- Yes
- No
Please give details*
Neurological*
- Yes
- No
Please give details*
Thalassaemia, sickle cell or other unusual haemoglobin*
- Yes
- No
Please give details*
Other*
- Yes
- No
Please give details*
Do you have a history of/current diagnosis of a mental health condition?*
- Yes
- No
If yes, please select from the following:
- Bipolar
- Obsessive Compulsive Disorder
- Personality Disorder
- Psychosis
- Post-Partum Psychosis
- Schizophrenia
- Schizoaffective Disorder
- Severe Depression (requiring hospital admission)
- Severe Postnatal Depression (requiring treatment)
- Other
Are you currently taking any medication or receiving treatment for any of the above?*
- Yes
- No
Please give details*
Are any of the following relevant to you, if "yes" please give details
Asylum seeker/refugee*
- Yes
- No
Please give details*
Have you or your family ever had a social worker / Keyworker*
- Yes
- No
Please give details*
Smoker*
- Yes
- No
Please give details*

Stopping smoking now will make a big difference to your health and the health of your baby. For support and free Nicotine Replacement Therapy please contact our Healthy Pregnancy Support Workers, they can be contacted via email - esht.maternitytdtservices@nhs.net or you can call/message 07977 093808
Substance abuse (including your partner)*
- Yes
- No
Please give details*
Violence/domestic abuse*
- Yes
- No
Please give details*
Any other information
Any additional information you feel is relevant - please enter below
Please tick this box and follow instructions to continue

Please note

Once you have completed your self-referral, please click the ‘Please click here to make your referral’ button. You will be sent an email* confirming that we have received your details.

Your information will be processed and you will receive an ‘Ultra Scan Appointment’ through the post. The Community midwife will aim to contact you prior to the Ultra Sound scan appointment, where they will liaise with you regarding a convenient date and time to perform your booking.

*subject to you entering a valid email address.

Your information

The information you enter into this form will be used to prepare for your visit for the birth of your child. Everyone working at the Trust must keep your information confidential and secure and share it only when necessary to provide you with the proper care during your stay. The fields marked * are compulsory but it is recommended that you complete as many optional fields as you can so that we have enough information to contact you in the case of a cancellation. By completing these optional fields you consent to us contacting you via this method. For example, by entering a phone number you consent to us contacting you by telephone. In this case you should bear in mind that someone other than yourself may answer the phone.

A copy of this form will also be sent to your GP to notify them that you are planning on having your baby at your selected hospital.

Important

This website is secure and the information you enter on this form is secure (please see the padlock symbol in the address bar).

Footer

X
Facebook
LinkedIn
Instagram

Conquest Hospital
Eastbourne District General Hospital
Bexhill Hospital

East Sussex Healthcare NHS Trust

CQC overall rating

Good

27 February 2020

See the report

Home
Accessibility
Cookie information
Privacy notice
Terms and conditions
© Copyright 2025 East Sussex Healthcare NHS Trust

Notifications