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The Statutory Maternity Pay (Medical Evidence) Regulations 1987

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[F1PART IIU.K.FORM OF CERTIFICATE

MATERNITY CERTIFICATEU.K.

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 [F2than 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 means a period of 7 days starting on a Sunday and ending on a Saturday.
Date of examination ......../........../........Registered midwives
Date of signing ......./........../........ Please give your [F3NMC] Personal identification Number and the expiry date of your registration with the [F3NMC] .

_________________

_________________

___________________________________
Signature:

Doctors

Please stamp your name and address here [F4(unless the form has been stamped, in Wales, by the Local Health Board in whose medical performers list you are included or, in Scotland,] [F5by the Health Board in whose primary medical services performers list you are included)].

______________________________]

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