Congratulations on your pregnancy! 

Please complete all relevant details as soon as possible following your positive pregnancy test so we can book you in for your first appointment in a timely manner. Any missing information may slow this process. You will normally be seen for your first appointment between 8 to 10 weeks, depending on your gestation when we receive your self-referral. 

We advise that all pregnant women take 400 micrograms of Folic Acid until they are 12 weeks pregnant and 10 micrograms of Vitamin D a day for the duration of their pregnancy. For more information please see planning your pregnancy and pregnancy pages. 

Download the free Baby Buddy 2.0 app, which features helpful information from each of the maternity units across North East London, including Queen’s Hospital. 

Your details

Note: Questions marked by * are mandatory

Title

*This is a mandatory field. First name

*This is a mandatory field. Surname or family name

Previous name (if any)

*This is a mandatory field. Date of birth

DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Address

Postcode

Enter your NHS number (if known)

Enter your Hospital Number (if known)

Can we contact you via email?

Yes
No

If yes, what is your email address?

Contact number (mobile or landline)

Can we call you on this number?

Yes
No

Do you require an interpreter? (please note: family members or partners cannot be used as interpreters)

Please Select An Option YesNo

If yes, preferred language?

	Yes	No
Sight problems?
Hearing loss?

* Spam Guard: What is the next number after 5? Write the number as a word.