Emergency contact: +31 6 532 02 915

Desire to have children

You have a wish to have children and want to attend our consultation hour! Welcome. To sign up, please fill out and send in the form below. Or feel free to sign up by contacting us by phone.

  1. First Name(*)
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  2. Surname(*)
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  3. Date of birth(*)
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  4. Address(*)
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  5. Postcode(*)
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  6. City(*)
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  7. Email address(*)
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  8. Phone number during the day(*)
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  9. Mobile phone(*)
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  10. Name of general practitioner(*)
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  11. Name of insurance(*)
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  12. Have you been pregnant before?(*)

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  13. If you have, please fill out the following numbers:
  14. Number of pregnancies
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  15. Number of miscarriages
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  16. Number of abortions
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  17. Number of children
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  18. When was your last child born?
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  19. So we can fully prepare ourselves for your specific situation, we ask that you fill out the extensive questionnaire on "Zwangerwijzer" and send this to us three days before the consultation at the latest, at Dit e-mailadres wordt beveiligd tegen spambots. JavaScript dient ingeschakeld te zijn om het te bekijken..
  20. (*)
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