You can refer yourself to our maternity service at Colchester Hospital
Please use the information below to complete an email to our maternity team.
The information you submit will be treated in confidence and in order to provide appropriate care for you and your baby we may need to share information with the wider care team. We will take your email as an agreement to share your information.
To self refer please include the following information in an email to firstname.lastname@example.org
You will receive an email response from us within 14 days – please check your junk folder for this if it does not come to your inbox.
Please do not resubmit the referral form, if you have not had an email response from us within this timeframe please contact us on 01206 742369.
Any information you send to the maternity team will be from an unsecure server, however any reply you receive from the team will be sent via a secure server. For more information, please click HERE.
Please be sure to include all of this information otherwise we will not be able to accept your referral.
You can copy and paste the text below into your email.
You doctor’s details
The name of the doctor you are registered with
The name of the surgery where you are registered
Your title (e.g. Mrs, Miss, Ms)
Your full name (First name and Surname)
Your previous Surname (If you had one)
Your date of birth (in format dd/mm/yyyy)
Your NHS Number (If known)
Your Hospital Number (If known)
Your post code
Your contact number
Your email address
Your preferred method of contact (e.g. email, phone)
Your first language (if not English)
If you require an interpreter (interpreter required, no interpreter)
If you have lived in the UK for the past year
Medical and obstetric (maternity) history
What was the first day of your last period (in format dd/mm/yyyy)(approximate date if not sure)
The number of previous pregnancies you have had (if none please state ‘no previous pregnancies’
If you have had a miscarriage before (if none please state ‘no miscarriages’
If you have had any terminations before (if none please state ‘no terminations’
Please tell us of any other medical conditions you have
If you are a smoker (e.g. smoker, non-smoker)
If you have any previous pregnancy history (e.g. caesarian section, Pre-eclampsia)
Next of Kin details
Name of next of kin (First name and Surname)
Next of kin date of birth (in format dd/mm/yyyy)
Next of kin address
Next of kin post code
Next of kin contact number
Next of kin Relationship to you (e.g. partner, mother)
Please note: If you have diabetes, please also refer yourself to the North East Essex Diabetes Service (NEEDS). Either ring on 0345 241 3313 option 2 or email on Referral.email@example.com
- Are you and/or the baby’s father carriers of sickle cell, thalassaemia or another haemoglobin variant?
- Are you already known to have HIV, Hepatitis B or Syphilis?
- Have you had a baby previously who was born with a chromosomal or genetic condition such as Down’s, Edward’s, Patau’s Syndrome, duchenne’s syndrome, cystic fibrosis? (this list is not exhaustive)
If so, please also contact the Antenatal and Newborn Screening Team at
firstname.lastname@example.org with your name, contact details and details of the above.Back to top