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Self-referral to community midwifery


This service is only for patients self-referring to Northampton General Hospital.

Please complete this form as soon as possible, following your positive pregnancy test.

Please provide all of the information requested. A list of what is required can be found below. You will find completing this form easier if you have this information available before you begin.

Once this form has been completed it will be sent to the Community Midwifery Service where a community midwife will be in touch on the number you have provided to arrange your first midwife appointment. This may be between 8 and 10 weeks of pregnancy, or sooner.

If you have any difficulty or require any assistance with completing the form, please contact 01604 545430 (Monday- Friday 8:30-16:00).

Before you fill out this form, you will need…

This form should take 10 – 15 minutes to complete. The data you enter into the form will expire after two hours, if you find that it is taking more than two hours to complete, you will need to start from the beginning.

Before you start completing this form, there is some information you will need to have available:

  • Personal information including your full name, date of birth, email address, mobile phone number, address, and NHS number. If you do not know your NHS number, you can find it using the NHS online service.
  • Health information including the first date of your last period.
  • Any active medical conditions you may have including diagnosis dates.
  • Any medications you take including herbal or homeopathic remedies including names and dosages.
  • Your Coronavirus (COVID-19) vaccination status, please have available the number of vaccine doses you have received and self-isolation dates if you are currently self-isolating.

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