Application form Application form First name: Last name (only birth name): E-mail: Date of birth: Telephone number: BSN: Address: Zip code: Reason registration: Make a choiceDesire to have childrenPregnancyBirth controlOther subject Date first day of last menstrual period: Additional message: Or either Sent a mail to info@verloskundigenwageningen.nl with your phone-number and we call you back. Or call us during 09:15 and 12:00 at 0317-411971