Mother's first and last name
*
Mother's date of birth
*
Partner's name
Baby's gender
Where are you going to give birth and who are you taking with you?
Which positions would you definitely want to try?
May a student attend your delivery?
How do you feel about pain relief?
How do you feel about pain relief?
How did you prepare for pregnancy (course/book/video)?
How do you want to feed your baby?
Specific/personal requirements
E-mail
*
voorbeeld@voorbeeld.com
Are you being treated by Midwives De Singel?
Yes
No
If you answered the previous question with 'No':
Do you live in the Dordrecht-region and would you like us to contact you?
Yes
No
We store your data carefully in accordance with our privacy conditions. Do you agree with this?
*
Ja
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