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Home
A-Z of Services
Hospitals
Antrim Area Hospital
Causeway Hospital
Dalriada Hospital
Holywell Hospital
Mid Ulster Hospital
Moyle Hospital
Robinson Hospital
Whiteabbey Hospital
General Information
Health and Care Centres
Ballymena Health and Care Centre
Braid Valley Care Complex
Health and wellbeing
Arts and Wellbeing
Diabetes Prevention Programme
Healthy Lifestyles
Health Literacy
Mental health and wellbeing
Older People’s Health
Physical Activity
Rural Health
Stop Smoking
About the Trust
What we do
Working for us
Get involved
Corporate Information
Trust Board
Board meetings and papers
Committees
Management and Board
Our finances
Our performance
Corporate plans, reports and strategies
Equality and Diversity
Research and Development
Intellectual Property
Governance
Partnerships
Lists and Registers
Procurement
Accessing information
Volunteering
Donations
Latest News
Get in touch
Maternity referral form for Causeway Hospital
Electronic Referral For Maternity Services at Causeway Hospital, Coleraine
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
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
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
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Forename(s)
Surname
GP Address
Street Address
Address Line 2
City
Postcode
I would like to be contacted regarding care with the Lotus Midwifery team (a continuity of care team in Causeway Area)
**AVAILABLE IN CAUSEWAY ONLY**
Yes
No
The 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 midwiferycontinuity@northerntrust.hscni.net
Please include your height (cms) and weight (kgs)
Height
Weight
Maternity information
Previous pregnancies
Please enter a number in the appropriate column(s)
Live Children
Ectopic
Miscarriage
Stillbirth
Neonatal Death
Previous births (number of each)
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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