First and last name *
Date of birth *
Street + house number *
Postal Code *
City
Telephone number
Mobiel*
Email*
Current GP
How many pregnancies
Any previous pregnancies guided by us? YesNo
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.
Morning (9 - 12 uur)
Afternoon (12 - 15 uur)
Monday Maandag Ochtend (9 - 12 uur) Afternoon (12 - 15 uur)
Tuesday Maandag Ochtend (9 - 12 uur) Afternoon (12 - 15 uur)
WednesdayMaandag Ochtend (9 - 12 uur) Afternoon (12 - 15 uur)
Thursday Maandag Ochtend (9 - 12 uur) Afternoon (12 - 15 uur)
Friday Maandag Ochtend (9 - 12 uur) Afternoon (12 - 15 uur)
Remarks (optional)