Self-refer online

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 at 8 to 10 weeks, depending on your gestation when we receive your self-referral.

To help you make choices about your care, please read the following useful information:

Please note: We have identified an issue with Android devices where the form does not come through to our team after submission. We are investigating the issue, so if you have not heard from us within 10 business days, please call us on 020 3315 7915 or 020 3315 7916 to look into your self-referral. We apologise for the inconvenience.

Personal details
Date of birth  
/ /  
Marital status  

Can we send text/sms messages to this number to notify you of appointments?  

Can we email you at this address?  


At which site would you like to have your care?   You can choose to have the majority of your care at either Chelsea and Westminster Hospital or West Middlesex University Hospital. Please note that in some cases some of your care may need to take place at the other site—this will be discussed with you if necessary.

Where have you lived in the last 12 months?   (please bring your passport or any other documentation you have to support your residency in the UK)

Your address
Next of kin
GP details
Current pregnancy
First day of your last period (if unsure, please leave blank and answer the next question)
/ /  
Are you interested in finding out more about a homebirth?  

Medical history
Medical and mental health history   (please tick all that apply)
Social complexities
Please tick all that apply  

Contact us


Chelsea and Westminster
T: 020 3315 6000

West Middlesex
T: 020 8321 5608

Mum and Baby app

Our Mum and Baby app supports your journey with us through your pregnancy, birth and life with your baby.

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