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Frank Ltd.
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Why us?
Why us?
Introduction from our Director of Midwifery
Midwifery Managers
Specialist Midwifery Team
Our Consultants
Our Consultants
Consultant Obstetricians
Consultant Anaethetists
Maternity Equality Diversity Inclusion group (MEDI)
Maternity Voices Partnership (MVP)
Patient Knows Best (PKB)
Professional Midwifery Advocates (PMA's)
Why us?
Birthing options
Birthing options
Home Birth
Birth Centre
Delivery Suite
Induction of labour
Induction of labour
Inpatient Induction of Labour
Outpatient Induction of Labour
Caesarean Birth
Birth After Caesarean (BAC)
Visitor and Partner Information
Visitor and Partner Information
Maternity Visiting guidance
Information for partners
Antenatal Care
Antenatal Care
Your Appointments
Your Appointments
Schedule of Care
Community Midwives
Sapling Antenatal Clinic
Early Pregnancy Unit (EPU)
Antenatal Screening
Ultrasound Scans
Medical Conditions in Pregnancy
Preterm Clinic
Maternity Assessment Unit (Tambootie Ward)
Parent Education
Parent Education
Parent Education Classes
Parent Education Videos
Managing Diabetes in Pregnancy
Managing Diabetes in Pregnancy
Diabetes pre-conception clinic
What is type 1 diabetes
What is type 2 diabetes?
What is gestational diabetes?
Smoking in Pregnancy
Vulnerable Women and Families
Vulnerable Women and Families
Domestic Abuse
Financial Support
Young families
Mental Health
Female Genital Mutilation (FGM)
Drug and Alcohol Misuse
Social Services
Mental Health Support
Mental Health Support
Self-assessment Tool- Perinatal Pathways
What we do…
Medication in Pregnancy and Breastfeeding
Dad/Partner's Mental Health
How to support your partner
I'm in crisis now and need urgent help
FAQs
Top tips for keeping well
Tokophobia/fear of childbirth
Information for professionals
Links for further support
Vaccinations in pregnancy
Vaccinations in pregnancy
Influenza vaccine – Flu
Pertussis vaccine – Whooping cough
Respiratory Syncytial Virus (RSV) vaccine - Bronchiolitis
Vaccination self-referral form
Postnatal Care
Postnatal Care
Postnatal Wards
Postnatal Wards
Aspen Ward
Cedar Ward
Community Midwife visits/ appointments
Screening tests for your New Baby
Special Care Baby Unit (Walnut Ward)
Mother and Baby Unit
Mental Health Support
Infant Feeding
Infant Feeding
Feeding and nurturing your Baby
Where to find infant feeding support
Prevention and self-help tools for Breastfeeding challenges
Your Baby's Emotional Wellbeing
Reflection and Resolution Service (Maternity Debrief)
Bereavement Service
Maternity and neonatal independent senior advocates
More information
More information
Parking information
Frequently asked questions
People you may meet
Maternity visiting information
360° images (virtual tour)
Maternity Feedback
Information leaflets
Stories from maternity service users
Maternity Annual Reports & Monthly Activity
Contact us
Contact us
Maternity Visiting Guidance
Having your baby at Darent Valley Hospital - online booking form
Community Midwives
Patient Advice and Liaison Service
Feedback
Social links
Maternity - Facebook
Maternity - Instagram
Maternity - YouTube
Pregnancy Self Referral
Vaccination self-referral form
You are here:
Home
Antenatal Care
Vaccinations in pregnancy
Vaccination self-referral form
Self referral form for vaccinations during pregnancy
First name
Required
Last name
Required
Title
Date of birth
Required
NHS / hospital number
Required
Due date identified by ultrasound / scan
Required
Your home address
Address 1
Address 2
City
State/Province
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Postal Code
Phone number
Required
Email address
Required
I consent for use of email to confirm appointment
Required
Yes
GP name
Required
GP surgery name and address
Address 1
Address 2
City
State/Province
Country
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Ascension Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Caribbean Netherlands
Cayman Islands
Central African Republic
Ceuta & Melilla
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo - Brazzaville
Congo - Kinshasa
Cook Islands
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czechia
Denmark
Diego Garcia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard & McDonald Islands
Honduras
Hong Kong SAR China
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau SAR China
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé & Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Barthélemy
St Helena
St Kitts & Nevis
St Lucia
St Martin
St Pierre & Miquelon
St Vincent & Grenadines
Sudan
Suriname
Svalbard & Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad & Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Outlying Islands
US Virgin Islands
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis & Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Postal Code
GP surgery phone number
Required
Do you have any allergies?
Required
Yes
No
If yes, what are you allergic to?
Have you had a reaction to any vaccines before?
Required
Yes
No
If yes, please explain what happened
Which vaccination would you like?
Required
Flu - available at any time during pregancy
Whooping cough (Pertussis) - from 16 weeks pregnant
Respiratory Syncytial Virus (RSV) - from 28 weeks pregnant
All of the above
Which day would you prefer to have your flu vaccination?
Monday - AM
Monday - PM
Tuesday - AM
Tuesday - PM
Wednesday - AM
Wednesday - PM
Thursday - AM
Thursday - PM
Friday - AM
Friday - PM
Which day would you prefer to have your whooping cough vaccination?
Monday - AM
Monday - PM
Tuesday - AM
Tuesday - PM
Wednesday - AM
Wednesday - PM
Thursday - AM
Thursday - PM
Friday - AM
Friday - PM
Which day would you prefer to have your RSV vaccination?
Saturday - AM
Saturday - PM
Sunday - AM
Sunday - PM
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Parent Education
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Infant Feeding
Maternity Assessment Unit
Ultrasound Scans
Your Appointments
Antenatal Screening
Mental Health Support
Maternity Visiting Information
