Personal data for the care by Härzchlopfä Hebamme Schritt 1 von 4 - All information will be treated confidentially and used only for our work and statistics. 0% Care for* Pregnancy Home birth Birth with attending midwife Postpartum care Personal detailsFirst and last name* Vorname Nachname Adress* Anschrift PLZ Ort Phone number*E-mail address* Date of birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Nationality*please selectUnited KingdomUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsMarital status*please selectmarriedunmarriedin registered partnershipdivorcedwidowedOASI number (a.k.a. AHV number)*First and last name of your partnerHow did you hear about us? Employment*Employed as* Employed or Self-employed Family wife as …at … %please select5101520253035404550556065707580859095100Resumption of employment away from home planned after ... weeksplease selectnot planned1234567891011121314more than 14If after more than 14 weeks Health dataBlood group and rhesus factor (mother)*please selectA+A-B+B-AB+AB-0+0-I am pregnant with my … childplease select1st2nd3rd4th5th6th7th8th9th10thThis is my … pregnancyplease select1st2nd3rd4th5th6th7th8th9th10th11th12th13th14th15thDue dateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Planned place of birthName and date of birth of older childrenTo add more children, click NameDate of birth Gynecologist*PediatricianHealth insurance* MiscellaneousWhere can we park our car at your place?CommentsPlace and date*Acknowledgement* I acknowledge that the registration hereby becomes definitive.*I give my consent for Härzchlopfä Hebamme GmbH to send me invoices electronically and thus for my child’s and my personal and health-related data to be used for the Swiss Federation of Midwives statistics. Yes No The provision of your data is optional. If you do not want your data to be included in SHV’s statistics and quality management, Härzchlopfä Hebamme GmbH will not send invoices directly to your insurance electronically, but will send you invoices for services you have acquired. In this case, you have to pay the invoice amount and submit it to your health insurance company for reimbursement. In this way, only the data necessary for invoicing is recorded.Consent* I agree to the privacy policy.*NameDieses Feld dient zur Validierung und sollte nicht verändert werden.
