Pregnancy Notification

Section

Approximate date of last period:

Please use this date format: DD/MM/YYYY.

The flu (Influenza) vaccination is strongly recommended for pregnant women.

Would you like to have the Flu Vaccination?

Yes

No

We offer the Flu Vaccination from October to January every year. If you fall pregnant outside of these months, we will automatically contact you to offer you the Flu Vaccination at the appropriate time.

You will also automatically be invited to attend for a Pertussis (Whooping Cough) Vaccination after 18 weeks of pregnancy.

Do you smoke?

Yes

No

Would you be happy for a Smoking Cessation Advisor to contact you?

Yes

No

Patient Signature: *

Completion Date of Form by Patient:

Midwifery Team

To help the hospital determine the correct Midwifery team you will be looked after by, once you have decided which hospital you would like to have your baby at, please ring the relevant number below.

If you wish to have your baby at West Suffolk Hospital:

Please call 01284 713755

If you wish to have your baby at Addenbrooke’s Hospital, please visit the following link to download the form and email to register the birth with the Rosie:

www.cuh.nhs.uk/rosie-hospital/maternity/pregnancy-pathway

When you contact the hospital, you will require your NHS number. If you do not know your NHS number, please tick this box and we will send you your NHS number by return.

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