Booking your birth with us

So that we can make your first appointment to meet us, please complete the self-referral form providing as much information as possible. Questions marked with an asterisk are mandatory.

Details of your midwife booking appointment will be emailed to you within seven working days. Please do not contact the booking coordinator unless you have not heard from us in seven working days.

Please note, for anyone that chooses to have their baby with us but lives outside the local area will receive their antenatal care from the Surrey Blossoms team. These appointments will be based at the hospital in antenatal clinic. Please be aware that once you have had your baby your will be referred back to your local hospital for your postnatal care. We unfortunately do not hold postnatal clinics for out of area patients. If you have any questions please do not hesitate to discuss with your midwife. 

Any referrals submitted between the 23rd May 2024 and 2nd June 2024 will not get a response until after the 3rd June. Please refrain from calling for an appointment as the team will not be able to provide you with a date, please wait for your booking email. 

If you have difficulties completing this form, or have not received your midwife booking appointment, contact the booking coordinator on 01483 464004.

We have different ways for you to access our services depending on your concerns, please visit our 'Contact Us' page for more information. 

Online referral form

Note: Questions marked by * are mandatory

Royal Surrey NHS Foundation Trust privacy notices and data security statements can be viewed on our Information Governance webpages.​​​​​​​ You can view our Information Governance page by clicking here.

*This is a mandatory field. First name: This should be as it appears in your NHS record.

*This is a mandatory field. Surname:

Previous name:

*This is a mandatory field. Date of birth:

*This is a mandatory field. Address - house name/number:

Address line 2:

*This is a mandatory field. Address - town/city:

*This is a mandatory field. Address - post code:

*This is a mandatory field. Do you consent for us to use your email and mobile number to set up your BadgerNotes account (this is where you can access your electronic maternity note) as well as to make contact with you about your referral?

Yes
No

*This is a mandatory field. Telephone number:

*This is a mandatory field. Email address:

*This is a mandatory field. NHS number: This should be 12 characters long e.g. 123 456 7890 Your NHS number can be found on any hospital letters, on your NHS app, via contacting your GP surgery or via the NHS checker: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

*This is a mandatory field. GP surgery/practice:

*This is a mandatory field. Are you transferring your care from another hospital?

Yes
No

If you are transferring your care please tell us which hospital you are transferring from.

*This is a mandatory field. First date of last period:

Have you had a scan in this pregnancy?

Yes
No

*This is a mandatory field. Ethnicity:

Please Select An Option Asian – Any Other Asian BackgroundAsian – Bangladesh or British BangladeshAsian – Indian or British IndianAsian – Pakistani or British PakistaniBlack – African or British AfricanBlack – Any Other Black BackgroundBlack – Caribbean or British CaribbeanChineseDeclined/ Refused to give informationMixed – Any Other Mixed BackgroundMixed – Asian and WhiteMixed – Black African and WhiteMixed – Black Caribbean and WhiteOther Ethnic GroupUnable to be asked/ ReplyWhite – Any Other White OriginWhite – BritishWhite - Irish

Do you require an interpreter?

Yes
No

What language do you need an interpreter for?

Please provide additional information relevant to your maternity care e.g. known pregnancy risk, expecting twins. (If you have immediate concerns call the pregnancy advice line on 0300 123 5473)

*This is a mandatory field. I confirm that I have checked the answers in this form and all my details are correct.

Yes
No