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?*
    YesNo

    Personal Details:

    Permission to call this number?*:
    YesNo

    Permission to leave voicemail?*:
    YesNo

    Permission to send text message reminders?*:
    YesNo

    Do you require an interpreter?*:
    YesNo

    Permission to contact you by email?*:
    YesNo

    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.