Registration

Great to hear that you want to register with us at the practice. After completing this form, we will receive an email and call you back as soon as possible to schedule a first appointment and/or an ultrasound. Of course you can also call us. The number of our obstetric practice is: 070-3468288

To make an initial appointment, you can reach our assistant on Monday to Friday between 9:00 AM and 12:00 PM and between 2:00 PM and 5:00 PM.

See you soon at our midwifery practice!

Fields marked with ^* are required.

Firstname of the mother-to-be ^*

Lastname of the mother-to-be ^*

Birthdate of the mother-to-be ^*

Burgerservicenummer (sofinumber) ^*

Address ^*

Zipcode ^*

City ^*

Mobile phone

E-mail address ^*

General practioner

Is this your first pregnancy check? ^*

Yes

Were you a client at our practice before?

Yes

Date of the first day of your last period ^*

Have you consulted a gynecologist earlier in this pregnancy? ^*

Yes

what is the name of the hospital and the gynecologist?

Do you want to be eligible for prenatal screening? ^*

Yes

Maybe

Do you have thyroid disease or does any of your first-degree relatives have thyroid disease (father, mother, siblings)?

Questions and/or remarks

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