Maternity Self-referral

Congratulations on your pregnancy!  Please use the form below to refer yourself to the Trust Maternity Service.

    Are you registered with a GP Practice in Blackpool, Fylde or Wyre?*

    Personal Details:

    Permission to call this number?*:

    Permission to leave voicemail?*:

    Permission to send text message reminders?*:

    Please select your ethnic origin*:

    Do you require an interpreter?*:

    Permission to contact you by email?*:

    GP Details:

    Additional information:

    About your pregnancy:

    (Please give approximate date, or leave blank if not known)

    This service is only available to patients registered with a Blackpool, Fylde or Wyre GP. If you are in the Blackpool, Fylde or Wyre area, but not registered with a GP, please visit your local GP to register.