Pregnancy Self-Referral Form

Please only complete this form if you are booked to give birth at, or are receiving your maternity care from Calderdale and Huddersfield NHS Foundation Trust.

Please contact the Maternity Assessment Centre (MAC) on 01422 224 392 if you have any pregnancy concerns. For example: vaginal bleeding, fluid loss or changes to your baby’s movements.

The form takes 15-20 minutes to complete, so please ensure you have time to complete the form fully in one sitting.

Please ask your GP to refer you to your local Perinatal Pelvic Health service.