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Frimley Park Hospital pregnancy notification form

If you are have any problems completing this form please contact your GP surgery who will pass on your details to the midwife.

We are committed to providing continuity of care to as many of our women as possible and are currently in the process of developing specialist continuity teams.
These midwifery teams will have enhanced knowledge and expertise and access to the wider multidisciplinary team to support many individual needs.

If you think any of the questions here apply to you please indicate yes in the form.
Answering yes will ensure you will be able to access the most appropriate team to look after you.
• Are you over 24 weeks and been worried to tell anyone you are pregnant? 
• Are you younger than 17 years old?
• Have you had a child looked after by social services, either placed in short or long term foster care or placed for adoption?
• Are you currently supported by Social Services and under a public law outline plan ?
• Have you been diagnosed with Post Traumatic Stress Disorder (PTSD)?
• Do you have learning disabilities that mean you need support every day? 
• Are you / is your family currently experiencing domestic abuse?
• Do you have a current drug or alcohol problem and have or want additional support from a drug or alcohol support service? 
• Are you new to this country or area with no or limited support?
• Are you living in temporary hostel or bed and breakfast accommodation? 
• Have you had significant Female Genital Cutting (FGC/FGM)?
• Have you attempted suicide within the last 3 months prior to your pregnancy?
• Are you HIV or Hepatitis B positive? 

Frimley Park Hospital pregnancy notification form

form
Do any of the above statements apply to you?


Please complete all sections below. Information submitted will be treated in confidence, but will be shared with those involved with your care. Please confirm and agree to this statement before proceeding. Fields marked * are mandatory.

Confirm and agree

This form is for having your baby at Frimley Park Hospital? *

Do you require additional support for sensory impairment?



Do you require interpreting services? *


Are you considering a home birth?


Do you have diabetes?*



Your details

NHS number is 10 digits eg 1234567890 - if you do not know your NHS number please contact your GP surgery for help. Incorrect or missing information may lead to a delay in processing this form.
Can we contact you by text on this number? *


First day of your last period * Please give approximate date if unsure

Your GP details

Are you planning on registering with a new GP soon?


Your next of kin's details

Transferring from another hospital

Please complete this section if you are transferring your care from another hospital

Covid-19 update - We are currently conducting telephone appointments You will be contacted within the next 10 days either by phone or post with further details.

Frimley Health NHS Foundation Trust provides maternity care at Wexham Park Hospital and Frimley Park Hospital. Information submitted through forms on this website are encrypted and  will be dealt with in accordance with data protection legislation.