Please fill in this form in ink

Name of patient _________________________________

Fill in this part if you are giving the certificate before the confinement.

Fill in this part if you are giving the certificate after the confinement.

Do not fill this in more F3than 20 weeks before the week the baby is expected.

I certify that I attended you in connection with the birth which took place on ......./........../....... when you were delivered of a child [__] children.

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 ......./........../........

In my opinion your baby was expected in the week that includes ......./........../........

"Week": This means the 7 days beginning on a Sunday.

Date of examination ......../........../........

Registered midwives:

Please give your F6NMC Personal Identification Number and the expiry date of your registration with the F6NMC.

Date of signing ......./........../........

Signature:

Doctors:

Please stamp your name and address here if the form has not been stamped by the F5F4Primary Care Trust or Local Health Board in whose medical performers list you are included (or, in Scotland, by the Health Board in whose primary medical performers list you are included)