Home birth self-referral

Please complete this form in order to make a self referral for a home birth at Milton Keynes University Hospital. In order to help us understand your individual needs, please answer the questions as fully as possible. This will ensure that you are booked for the most appropriate care.

Some of the questions you will be asked are in order for the team at the hospital to be able to provide you with the best possible care and ensure you are looked after by specialists if necessary.

Booking early in pregnancy has benefits for you and your baby. Prompt access to maternity care enables the timely offer of antenatal of antenatal screening tests. Screening tests are offered during pregnancy to find any health problems that could affect you or your baby. For more information on the screening tests that are available for you and your baby click here.

If you would like advice on weight management during your pregnancy, MoreLife offer a free service for those who live in Bedford Borough, Central Bedfordshire or Milton Keynes. For more information and to refer yourself to the service, visit the MoreLife website.

First name* Surname* Address line 1* Address line 2 Town/City* Postcode* Preferred phone number* Email address Date of birth* Country of birth Hospital number/NHS number What is your partnership status Ethnic origin* Do you identify with a religion? If yes, please specify which one GP Surgery address and phone number* Estimated height Estimated weight - It is important to accurately provide your current weight as it will be used to determine the care pathway in pregnancy Do you require an interpreter?* If yes, what is your first language? Do you have a learning disability Do you have any hearing problems? Do you have any sight problems? Are you a Type 1 Diabetic? Are you a Type 2 Diabetic? Have you ever been told you are a 'carrier' for sickle cell or thalassaemia? Has the biological father of your baby ever been told he is a 'carrier' for sickle cell or thalassaemia? Have you ever tested positive for HIV, Hepatitis B or Syphilis? What was the date of the first day of your last period?* Is this an IVF pregnancy? Preferred place of birth* How many previous pregnancies have you had? Have you had care with any other hospital during your pregnancy?

Home birth self-referral

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