Maternity referral form for Antrim Area Hospital

Electronic Referral For Maternity Services at Antrim Area Hospital

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 area:
You will also need to notify your GP of your pregnancy It is important to purchase & commence the following: • Folic acid = 400micrograms per day. • 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 >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) Surname
Date of Birth*
DD slash MM slash YYYY
Previous surname
Health and Care Number (please include if possible as it helps speed up the appointment process)
Address*
Street Address Address Line 2 City County Postcode
Email
Home phone
Mobile number*
Marital Status
Nationality
Ethnic Group
Interpreter required?
- Yes
- No
Language spoken
First day of last menstrual period or as close as possible*
DD slash MM slash YYYY
GP Name
Title Forename(s) Surname
GP Address
Street Address Address Line 2 City Postcode
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?*
- Yes
- No
Any relevant medical history? eg: diabetes, multiple pregnancy, IVF treatment etc
Prescribed medications
IF YOU ARE ON PRESCRIBED MEDICATION PLEASE CONTACT YOUR GP AS SOON AS POSSIBLE
Allergies
Do you have a Social Worker?
- Yes
- No
Name of Social Worker
Base
Contact number
Please visit www.northerntrust.hscni.net/BabyandU for early pregnancy advice prior to attending your booking appointment.

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Maternity referral form for Antrim Area Hospital

Electronic Referral For Maternity Services at Antrim Area Hospital

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 area:

You will also need to notify your GP of your pregnancy It is important to purchase & commence the following: • Folic acid = 400micrograms per day. • 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 >30 YOU NEED TO MAKE AN APPOINTMENT TO SEE YOUR GP AS YOU WILL PROBABLY NEED THE HIGHER DOSE OF FOLIC ACID

Maternity Information

Please visit www.northerntrust.hscni.net/BabyandU for early pregnancy advice prior to attending your booking appointment.

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