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Self-referral for pregnancy care - Northwick Park Hospital

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Maternity self-referral form
Personal details
Interpreter required?
Marital status
Partner's details
GP details
Current pregnancy
Past obstetric history (make note of any previous caesarean section, assisted delivery, and pregnancy outcomes)
Medical and psychiatric history (if answer is Yes to any of the following, please provide further details using the 'additional information' section)
Heart problems
Neurological
Lung/asthma/TB
Diabetes
Sickle Cell/Thalassaemia
Kidney problems
High blood pressure
Liver problems
Mental health problems
Other
Social history (if answer is Yes to any of the following, please provide further details using the 'additional information' section)
Drug/alcohol misuse (including partner)
Violence/domestic abuse
Child protection issues
Do you have a social worker
Any other mental health concerns
Disability eg deaf/blind/physical handicap
Smoked in last six months?
Current medication
Folic acid
Vitamin D
Please note that this is not a secure form and by entering your information into this form you are consenting for this to be shared using an insecure method. The information you supply could be held by (Ideagen) and on the server you are currently connected to. The information will then be sent without the use of an encrypted or N3 channel to a NHS.net account. As soon as the information reaches lnwh-tr.antenatalbookings@nhs.net, the information will be held securely and in line with the Data Protection Act 2018 as the Trust is in control of your personal information. 
 
Alternatively, please contact the service by phone on 020 8869 5252 or email lnwh-tr.antenatalbookings@nhs.net with regards to your self-referral to our Maternity services. 
 
A new form and site are being designed and will be implemented shortly. This will provide a secure way of sharing your personal data.