If you have just had confirmation that you are pregnant, Congratulations!
Information submitted will be treated in confidence but in order to provide appropriate care for you and your baby we may need to share information with the wider care team.
Emailing information to us will be taken as agreement to this statement.
To self refer please include in an email the following information, please be sure to include all of this information otherwise we will not be able to accept your referral. Send your email to email@example.com
For ease of use, copy and paste the text below into your email.
You Doctors Details
The name of the doctor you are registered with
The name of the surgery where you are registered
Your title (e.g. Mrs, Miss, Ms)
Your full name (First name and Surname)
Your previous Surname (If you had one)
Your date of birth (in format dd/mm/yyyy)
Your NHS Number (If known)
Your Hospital Number (If known)
Your post code
Your contact number
Your email address
Your preferred method of contact (e.g. email, phone)
Your first language (if not English)
If you require an interpreter (interpreter required, no interpreter)
If you have lived in the UK for the past year
Medical and Obstettric History
What was the first day of your last period (in format dd/mm/yyyy)(approximate date if not sure)
The number of previous pregnancies you have had (if none please state 'no previous pregnancies'
If you have had a miscarriage before (if none please state 'no miscarriages'
If you have had any terminations before (if none please state 'no terminations'
Please tell us of any other medical conditions you have
If you are a smoker (e.g. smoker, non-smoker)
If you have any previous pregnancy history (e.g. caesarian section, Pre-eclampsia)
Next of Kin Details
Name of next of kin (First name and Surname)
Next of kin date of birth (in format dd/mm/yyyy)
Next of kin address
Next of kin post code
Next of kin contact number
Next of kin Relationship to you (e.g. partner, mother)
Please note: If you have diabetes, please also refer yourself to the North East Essex Diabetes Service (NEEDS). Either ring on 0345 241 3313 option 2 or email on firstname.lastname@example.org