First and last name *
Date of birth *
Street + house number *
Postal Code *
How many pregnancies
Any previous pregnancies guided by us?
Date of birth of the youngest child and / or miscarriage
Contraception used until
Type of contraceptive
Average cycle time
First day of last menstrual period
Date of positive pregnancy test
The first appointment takes place at 8 to 10 weeks of pregnancy.
Our assistant will make an appointment with you. Please indicate below when our assistant can reach you.