Emergency contact: +31 6 532 02 915

Register for pregnancy

We’re happy that you’d like to sign up at our practice. To sign up with us, please fill out the form below. Of course, you can also get in touch with us by phone.

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

    Verplicht veld
  13. If you have, please fill out the following numbers:
  14. Number of pregnancies
    Invalid Input
  15. Number of miscarriages
    Invalid Input
  16. Number of abortions
    Invalid Input
  17. Number of children
    Invalid Input
  18. When was your last child born?
    Invalid Input
  19. Were you with Vita Nova during your last pregnancy?

    Verplicht veld
  20. What was the first day of your last period?
    Invalid Input
  21. Are you being seen or have you been seen by a gynaecologist?

    Verplicht veld
  22. If yes, what was the reason?
    Invalid Input
  23. (*)
    Invalid Input

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