Fields marked with an * are mandatory.

* 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
* 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)

* Due date
* Date of positive pregnancy test
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.