Fields marked with an * are mandatory.

  Particulars:
* Initials
 
* Surname
 
* Forename
 
* Date of birth (dd-mm-yyyy)
 
* Street name
 
* House number
 
House number suffix
 
* Postal code
 
* City
 
* Telephone number (landline)
 
  Mobile number
 
* E-mail address
 
* Citizen Service Number (BSN)/tax and social security number (SOFI)
 
  Name of the midwife practice
 
Astrid Limburg Verloskundigen
Onze Lieve Vrouwe Gasthuis
Verloskundecentrum NOVA
Verloskundigen Amsterdam Oost
Verloskundigenpraktijk Oostelijke Eilanden
Verloskundigen Ruyschstraat
Witsenkade Verloskundigen
* Have you already visited our practice before for a check-up?
  yes no
     
  Insurance:
* Name of insurance company
 
* Uzovi (Unique healthcare Insurer) code (4-digit code on the card)
 
* Policy numberPolicy number
 
     
  Check-up details:
* Date of the 1st day of last menstruation (dd-mm-yyyy)
 

of
* Due date
(dd-mm-yyyy)
 
* Date of positive pregnancy test
(dd-mm-yyyy)
 
Your height
 
Your weight at the commencement of pregnancy
 
     
* Contact
  Please call me to make an appointment (within 24 hours, weekend not included)
I will contact the Ultrasound scan centre myself to make an appointment
Other comments
 
  You will automatically receive confirmation per e-mail directly after sending in the form.