Registration form

Please use the form below to register with us for maternity care. Under the header ‘After registering’, you can read more about how registration works. Unfortunately we are already full till the end of May 2020. If your due date is before 1 June we recommend you to find another maternitycare buro.

Initials: *

Last name: *

E-mail address: *

Address: *

Phone number:

Language mother: *

Insurer:

Midwife:

Expected birth date of child: *

Desired place of delivery *:

Other place of delivery:

Type of residence:

Do you have pets? *:

If yes, which pets do you have? *:
DogCatBirdOther:

First name: *

Maiden name: *

Zip code and city: *

Mobile phone: *

Passport identification number: *

Date of birth mother: *

Civil status *:

Current number of children: *

If you have more children, please enter their names and birth dates below:

First names and birth dates children:

First name partner:

Last name partner:

Mobile phone partner:

Birth date partner:

Comments:

I am aware of the general terms of delivery of BO maternity care 2018, the general terms and privacy statementof Bureau Klasse Kraamzorg, I have understood these and I agree to these. *

I hereby consent to the processing of my data by Bureau KlasseKraamzorg for the purposes of the requested care. *

* Obligatory fields

After you register, our cancellation terms apply. These can be found in our terms of delivery and in the national terms of delivery. Finally, we would like to point out that Bureau Klasse Kraamzorg handles your personal data correctly and according to the AVG, you can read this in our privacy regulations.