Self referral form

As soon as you find out you are pregnant you are very welcome to contact us directly to talk about using our services. You can send us a self-referral form or ask your GP for a referral. We look forward to hearing from you.

You can download our self-referral form below, fill it in and either email or post it to us.

Note: the security settings of your browser may prevent it from downloading the Word document properly. If this is the case, please email us requesting the Word form and we will email it back to you. Or you could use the PDF file, scan the completed form and email it or post it back to us.

The email address is:


The postal address to send it to is:

Maternity Unit
West Middlesex University Hospital NHS Trust
Twickenham Road
Middlesex TW7 6AF