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Please be aware, the information on this page relates to Luton & Dunstable University Hospital

Early Self-Referral to Maternity Services at the L&D

Please note this form is for patients self-referring to the L&D

Once this form has been completed it will be sent to the Community Midwifery Services who will arrange your initial booking appointment with you, on the number you provide below.

Please contact us if you have not heard from us within 10 working days, you can call 01582 497020, this number will get you through to maternity reception, Monday to Friday, 8am to 6pm.

Please click here to read about screening information

PLEASE DO NOT FILL IN THE FORM BELOW BEFORE READING THE SCREENING INFORMATION ABOVE.

Antenatal Self-Referral

Please complete all fields marked with an astrix (*)

Any previous pregnancies?

If yes, were any born at the L&D?

Is English your first language?

If no, do you require an interpreter?

Do you have a disability?

Do you currently consider yourself to have any medical problems?

Thank you for your enquiry, we will be in touch shortly.

Please note this form is for patients self-referring to the L&D