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.