Make, change or cancel an appointment with our online Klinik services.

Self-Registration Form for Maternity Care

Please share with us any information that you think is relevant to providing care for yourself or your baby. The answers you provide will allow us to pass your registration to the correct Midwifery or Obstetric Team; therefore it is essential that you share as much information as possible.

Registrations can also be made by calling your local community midwives’ office on (Aylesbury) 01296 316120 or (High Wycombe) 01494 425172.

Please do not use this service for any urgent medical queries as this service is only monitored during practice working hours on a daily basis.

Please note: If you have an urgent medical query you should telephone the surgery or contact the out of hours service by calling 111.

Self-Registration Form for Maternity Care
Are you completing this form on behalf of someone else? *

Your Details

Mother’s Information

Please specify which surgery you are a patient at *

Your Height and Weight


Unit of measurement *



Medical History

Do you take regular medication? *
Please state yes or no

Your Medication

Have you ever experienced either of the following? *

Diabetes Information

If you have both conditions

Thyroid Information

Current Pregnancy Information

Do you know the date of the 1st day of your last period? *
Have you thought about about where you would like to birth your baby? *

Social History

Have you ever had support from a social or family support worker? *
Do you currently drink more than 14 units of alcohol a week? *
Do you smoke tobacco? *
Have you ever taken recreational drugs? *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.