Care by Härzchlopfä Hebamme - Härzchlopfä Hebamme

HH_06_Praxis_1180@2x

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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.

Care for*
- Pregnancy
- Home birth
- Birth with attending midwife
- Postpartum care
Personal details
First and last name*
Vorname Nachname
Adress*
Anschrift PLZ Ort
- Phone number*
- E-mail address*
- Date of birth*
- Nationality*
- Marital status*
- OASI number (a.k.a. AHV number)*
First and last name of your partner
How did you hear about us?

Employment
Employed as
- Employed or Self-employed
- Family wife
- as …
- at … %
- Resumption of employment away from home planned after ... weeks
- If after more than 14 weeks

Health data
- Blood group and rhesus factor (mother)*
- I am pregnant with my … child
- This is my … pregnancy
- Planned date of birth
- Planned place of birth
Name and date of birth of older children
To add more children, click
Name Date of birth
Gynecologist*
Pediatrician
Health insurance*

Miscellaneous
Where can we park our car at your place?
Comments
Place and date*
Acknowledgement*
I acknowledge that the registration hereby becomes definitive.*
Consent*
I agree to the privacy policy.*
Phone
Dieses Feld dient zur Validierung und sollte nicht verändert werden.