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 Oosterpark
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.