You can register with our practice by completing the online form below. When the form has been submitted, you will receive an automatic confirmation. Following this our assistant will contact you as soon as possible to schedule your first appointment.

 

Form 1. Registration

  • Personal details

  • Highest level of qualification achieved
  • Apotheek

  • Partner's details

  • Highest level of qualification achieved

  • Pregnancy details

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
    number of days between periods (eg. 28)
  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
    if you have done one
  • treatment type, dates and health care provider
    We actively support the Mother's for Mother's initiative that helps women with fertility issues to be able to get pregnant. To this end we would like to pass on your telephone number to the local representative who will contact you to give you further information about this initiative (with no obligation). We encourage you to consider helping this worthy cause, however, if you prefer not to be contacted, please check the box. www.moedersvoormoeders.nl
    We will send you email updates with relevant information during your pregnancy as part of the care you receive in our midwifery centre. *Please note - this information is purely to support our care and we will never pass your details on to third parties.
    Your partner can also choose to receive our email updates throughout your pregnancy, this can help when preparing and planning together. *Please note - this information is purely to support our care and we will never pass your details on to third parties.
  • This field is for validation purposes and should be left unchanged.