Name of patient : ......
Part A
Fill in this part if you are giving the certificate before the confinement.
Do not fill this in more than 20 weeks before the week when the baby is expected.
I certify that I examined you on the date given below. In my opinion you can expect to have your baby in the week that includes .../.../...(tu wpisuje date).
Week means a period of 7 days starting on a Sunday and ending on a Saturday
TO THE PATIENT
Please read the notes on the back of this form
Part B
Fill in this part if you are giving the certificate after the confinement.
I certify that I attended you in connection with the birth which took place on .../.../... when you were delivered of a child [ ] children.
In my opinion your baby was expected in the week that includes .../.../...
Date of examination .../.../...
Date of signing .../.../...
Signature
Registered midwives
Please give your UKCC Personal Identification Number and the expiry date of your registration with the UKCC .........
Doctors
Please stamp your name and address here if the form has not been stamped by the Health Authority in whose medical list you are included.
[ Ostatnio edytowany przez: ania_caterham 29-08-2009 20:04 ]