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Self-Referral Form for Maternity Care in Antrim (with Antenatal Care in Causeway locality)

Are you newly pregnant and wish to contact your midwife?
As soon as you have a positive pregnancy test you can refer yourself directly for maternity care in the Northern Health and Social Care Trust.
You will also need to notify your GP of your pregnancy. It is important to purchase and commence the following: Folic acid (400 micrograms per day) and Vitamin D (10 micrograms per day especially from September to April).
If you are a known epileptic or there is a family history of spina bifida or your BMI is greater than 30, you need to make an appointment to see your GP as you will probably need the higher dose of folic acid.
If you are planning a pregnancy, you can buy multivitamins that are suitable for pregnancy (your local pharmacist can advise) and start at least 12 weeks before you get pregnant. When you are pregnant, if you have not already started this medication, it is very important to start as soon as possible and continue for at least the first 12 weeks of your pregnancy. Please ensure all details are accurate.
Name*
Title Forename(s) in full Surname
It is essential that you contact your GP to update their records with your new name, before the maternity booking appointment
Previous surname
Date of Birth*

Day
Month
Year
Address*
Street Address Address Line 2 City County Postcode
Health and Care Number (please include if possible as it helps speed up the appointment process)
Email
Home phone
Mobile number*
Marital Status
Nationality
Ethnic Group
Interpreter required?
Language spoken
First day of last menstrual period or as close as possible*

Day
Month
Year
Your occupation
Your partner's occupation
GP Name
Title Forename(s) Surname
GP Address
Street Address Address Line 2 City Postcode
Height (cms)
Weight (kg)
Next of Kin details
Next of Kin Forename Next of Kin Surname
Relationship to you
Next of Kin Address*
Street Address Address Line 2 City County Postcode
Telephone number
Work telephone number
Continuity of Midwifery Carer team Geographical area of Causeway
I would like to be contacted regarding care within the Continuity of Midwifery Carer Team (CoMC)
The Continuity of Midwifery (Lotus Team) are a small dedicated team of Midwives who offer continuity of midwifery carer throughout your pregnancy, birth and early parenting period. We aim to offer holistic care with a named midwife who you will build a trusting relationship with on your journey. For more info on the lotus team please contact comc@northerntrust.hscni.net
Maternity information
Previous pregnancies
Please enter a number in the appropriate column(s)
Live Children Ectopic Miscarriage Stillbirth Neonatal Death
Previous births
Please enter a number in the appropriate column(s)
Unassisted Vaginal Birth Assisted Vaginal Birth Caesarean Section
Assisted Vaginal Birth
Please enter a number in the appropriate column(s)
Forceps Vacuum
Previous blood transfusion at any stage before or after the birth?
Any relevant medical history or pregnancy information? E.g. diabetes, multiple pregnancy, IVF treatment etc.
Severe Mental Illness - Have you ever been treated for Bi-Polar disorder, Schizophrenia or Psychosis? Please comment
Do you consent to onward referral for specialised mental health support?
Prescribed medications
If you are on prescribed medication please contact your GP as soon as possible.
Allergies
Do you smoke?
Do you vape?
If you do smoke/vape, being pregnant is a great reason to give up for good. You will be referred to a smoking cessation midwife at your booking appointment, but if you want advice and support on giving up prior to that appointment you can contact the smoking cessation midwife in your area. Annette Barclay, Causeway area, , Mobile: 075 8402 3601 Gillian Ross, Antrim/Ballymena Area, Mobile: 078 8764 7915 Sandra Duffy, Newtownabbey/Larne/Carrickfergus area, Mobile: 078 2787 4334 Kerry Bate, Mid Ulster Area, Mobile: 077 8669 3890
Do you have a Social Worker?
Name of Social Worker
Base
Contact number
If you have any queries regarding this form or if you have not received an appointment by the 11th week of your pregnancy please contact the appropriate booking department; • For Causeway locality - Referrals Office on 028 7032 7022 • For all other areas - OPD4 on 028 9442 4537

Self-Referral Form for Maternity Care in Antrim (with Antenatal Care in Causeway locality)

Self-Referral Form for Maternity Care in Antrim (with Antenatal Care in Causeway locality)

Are you newly pregnant and wish to contact your midwife?

As soon as you have a positive pregnancy test you can refer yourself directly for maternity care in the Northern Health and Social Care Trust.

Continuity of Midwifery Carer team Geographical area of Causeway

Maternity information

If you have any queries regarding this form or if you have not received an appointment by the 11th week of your pregnancy please contact the appropriate booking department; • For Causeway locality - Referrals Office on 028 7032 7022 • For all other areas - OPD4 on 028 9442 4537

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