Antenatal Booking Form

Select ‘find out more about Jade Team’ at the end of this booking form and a member of the team will be in contact with you.

In order that we can make your first appointment for you to meet us, please complete your details below. We will then get back to you within 10 (ten) working days regarding your appointment. We aim to see you before you are 12 weeks pregnant.

Title:

Mrs

Miss

Other

Please state

First name:

Last name:

Any other names (including maiden name):

Date of birth:

Address (where you live):

Postcode:

Hospital number (if known):

Telephone number:

Is it OK to contact you by phone?

Yes

Email address:

Please confirm your email address:

Is it OK to contact you by email?

Yes

Have you lived in the UK for the last 12 months?

Yes

What is your Ethnicity?

Do you need an interpreter?

Yes

Which language is required?

Name of Doctors Surgery:

How many weeks pregnant do you think you are?

Do you know the first day of your last period?

Yes

Enter the first day of your last period

How many children do you have?

Partner's name:

Partner's address:

Partner's telephone number:

Next of Kin's name:

Next of Kin's address:

Next of Kin's telephone number:

Any relevant information including medical or family history:

Have you had any thoughts about where you would like to have your baby? Your midwife will also discuss the options with you.

North Bristol NHS Trust which includes options at Southmead Hospital, Mendip Birth Centre, Cossham Birth Centre or at home

University Hospitals Bristol NHS Foundation Trust which includes St Michaels Hospital, the Midwifery Led Unit and Ashcombe Birth Centre (Weston-super-Mare) or at home

United Hospitals Bath NHS Foundation Trust which includes the Royal United Hospital, Birth Centres across Wiltshire and Somerset or at home

Undecided

Do you have access to a smartphone to download our free MyPregnancy@NBT app?

Yes

Funded by Southmead Hospital Charity the App offers you a range of information about pregnancy, labour and birth. It replaces paper patient information leaflets and is easy to use anytime, anywhere.

Download the MyPregnancy @ NBT app from Apple iTunes at https://itunes.apple.com/gb/app/mypregnancy-nbt/id1282495682?mt=8 or Google Play at https://play.google.com/store/apps/details?id=uk.co.horizonsp.mypregnancywl or search the app store for MyPregnancy @ NBT.

If you do not have access to a smartphone please inform your midwife who will print patient information for you.

There are antenatal and birth choices available to you. You may be able to have your care with Jade Team at Cossham Birth Centre.

Antenatal Booking Form