Direct to Midwife - Referral for Maternity Care

Please complete the details requested below and return to - community.clerks@mft.nhs.uk

Please indicate where you would like to Birth your baby

Choices :- Saint Mary’s @ Oxford Road Campus or Saint Mary’s @ Wythenshawe, Ingleside (Salford) or Home
or other eg Bolton, Warrington, North manchester

please type your choice here.

Saint Mary`s @ Wythenshawe

Date of completing form: 18/05/2021

Name: Lisa janila Pereira Furtado Monteiro

Previous Name (if relevant):

Date of Birth: 07/12/95

Address: 5 Beckton Gardens

Post Code: M22 9QR

Telephone Number: 07453820908

Email: pablo002002@hotmail.com

How long have you legally lived in the UK. 6 weeks

NHS Number (if known): 725 438 1355

Which GP Practice are you registered with: Cornishway Group Practice

Your ethnic Origin / Nationaltiy (Cape Verde, black Caribian )

Ethnic Origin / Nationaltiy of Partner / Father of baby: portuguese

Is English your first Language? Yes / No (×)

If No please state your first language: Portuguese

Do you require an interpreter? Yes(×) / No

Have you travelled abroad in the last 6 months? Yes / No

If yes to above where? I have been living in UK for 6 weeks and since i been here i have never go to
nowhere, i came from Portugal. I am in UK since 30/03/2021

What was the first day of your last period: 12/04/2021

Due date (if known): 17/04/2021

Are you currently taking Folic? Yes / No (×)

If no please contact your Local pharamacy for advice.

Previous Obstetric History:
Please state if this is your first pregnancy.
If you already have children please state how many and the type of delivery you had, eg, normal
delviery, c-section, forceps etc. and if there were any problems or issues during the pregnancies or
births.

Medical / Surgical History or Allergies: Please state if you have any ongoing medical problems or any
medical issues in the past, or any allergies:

Previous Medical History:

Are you transferring your care from another hospital? If yes please state which hosiptal and the reason
you are transferring?

It is recommended that you contact your GP to have both the flu and whooping cough vaccines during
your pregnancy. The flu vaccine can be done at any stage of your pregnancy during the flu season and
the whooping cough vaccine from around 20 weeks.

You will receive a letter with you booking appointment by post within 10 days. If you have not received a
letter in that time frame please email community.clerks@mft.nhs.uk.

Below are websites that are contain useful information about the services offered at Saint Mary’s,
Oxford road and Wythenshawe including The Manchester Birth Centre based at Wythenshawe and
Ingleside (free standing unit in Salford)

www.mft.nhs.uk

www.bolton.nhs/services/maternity

To prepare for your pregnancy a useful guide is available at www.nhs.uk

Your pregnancy and baby guide.

This has useful information about healthy eating and healthy lifestyle, for example the effects of alcohol
in pregnancy, stopping smoking, important vitamins for your pregnancy and foods to avoid. It also has
useful guides for care during pregnancy, labour and after the birth of your baby.

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Date/time referral actioned ------------------------------- By ………………………………………………………

Date/time of booking apt. …………………………….. Venue ----------------------------------------------------------

Interpreter booked Yes □ No □