Congratulations on your pregnancy! To book your maternity care at South Warwickshire University NHS Foundation Trust, please complete the below form.

When you have completed and sent the form, you will receive a confirmation email containing maternity advice to the email address you have given. We will then be in touch within 5-7 working days, via email, to inform you of the dates of your:

  • Clinic appointment with a Maternity Support Worker where samples of your blood and urine will be taken and your blood pressure checked.
  • Booking appointment with a midwife, from the team that will be overseeing your maternity care, for when you are between 8 and 12 weeks pregnant.
  • Ultrasound scan for when you are around 12 weeks pregnant to ascertain when your baby is due.

If you do not hear from us, are unable to contact us electronically or have any difficulties answering the questions, please call the Bluebell Birth Centre, our base at Warwick Hospital, and we will assist you: 01926 495321 ext 6977.

Please check your junk mail folder for your confirmation email if it doesn't appear in your inbox.

Use of your information

An automated email containing advice about keeping well in pregnancy will be sent to you, using the email you have provided, on submission of your referral. The details of your appointments will also be sent to this email address. If you do not wish to be contacted in this way, please do not submit this referral form and call the Bluebell Birth Centre on the number above.

 Personal Information

Full Forenames: * Surname: * Previous Name: Address: * Postcode: * Date Of Birth: * Ethnic Origin: *
It is important that your ethnic origin is recorded in your maternity records. Everyone will have a personalised care plan and this information is essential for some of the pregnancy screening tests that will be offered to you. Your ethnic origin is where your family originate from, not your country of birth. Preferred Contact Telephone Number: * Can A Message Be Left: * Email Address: * NHS Number:
Click here if you dont know this   Registered GP: *
If your current GP practice is not listed, you will require an out-of-area referral. Please contact your local maternity team who can complete the specific referral we need.

 Medical Information

Is This Your First Pregnancy: * Date Of Last Menstrual Period: *
If you do not know the exact date, please add an approximate date in to this field. If you are very unsure, please add today’s date into this field. Then in 'Any other relevant information?' add how many weeks pregnant you think you might be. Any Medical Problems Or Any Other Relevant Information?
If you are unsure of the date of your last menstrual period, please put how many weeks pregnant you think you might be here. Are you diabetic? *
Smoker: * Do You Require An Interpreter? * Submitted By: *

 Personalised Care and Support Planning

We strive to provide safe, personalised, respectful and compassionate care for all the families choosing to birth with us.

The information on this form will help us get to know you better and plan your care with you in a personalised and inclusive way.

Things can change during your pregnancy journey and we can revisit this information with you to ensure we are meeting your needs.

What is important to you about your pregnancy & birth that you would like us to know? Tell us how we can best support you?
For example: with your Physical health? Mental Health? Social factors? Barriers to understanding? Communication difficulties? Are there any adjustments that would make your maternity journey easier?
For example: How we give you information? Accessing the maternity department areas? Attending appointments?
If you are happy with all of the information above, please click the button below. Please only click this button once.
Submit referral

Congratulations on your pregnancy!

×

To book your maternity care at South Warwickshire University NHS Foundation Trust, please complete the below form.

When you have completed and sent the form, you will receive a confirmation email containing maternity advice to the email address you have given. We will then be in touch within 5-7 working days, via email, to inform you of the dates of your:

  • Clinic appointment with a Maternity Support Worker where samples of your blood and urine will be taken and your blood pressure checked.
  • Booking appointment with a midwife, from the team that will be overseeing your maternity care, for when you are between 8 and 12 weeks pregnant.
  • Ultrasound scan for when you are around 12 weeks pregnant to ascertain when your baby is due.

If you do not hear from us, are unable to contact us electronically or have any difficulties answering the questions, please call the Bluebell Birth Centre, our base at Warwick Hospital, and we will assist you: 01926 495321 ext 6977.

Please check your junk mail folder for your confirmation email if it doesn't appear in your inbox.