You can register with us online by filling in this registration form, you will receive an automatic confirmation on completion. Once we have received your registration our assistant will call you as soon as possible to schedule an appointment.

Form 1. Registration

  • Personal details

  • Highest level of qualification achieved
  • Apotheek

  • Partner's details

  • Highest level of qualification achieved

  • Pregnancy details

  • DD slash MM slash YYYY
  • DD slash MM slash YYYY
    number of days between periods (eg. 28)
  • DD dash MM dash YYYY
  • 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.