Hi!

Thank you for your interest in the CMT Balbriggan Booking Clinic. We run this clinic on a Monday
morning between 9am and 1pm for women in their 12th and 13th week of pregnancy. At this
appointment, we will do your booking scan and check your weight/height/blood
pressure/urine/take your bloods as well as giving you antenatal information. In order to keep to a
one-hour timeslot we will ring you at some stage in the week prior to your appointment take a
booking history from you over the phone.
As the clinic does not have a doctor at the clinic, we cannot accept higher risk women who need
obstetric review at booking.
If you would like to have your booking visit in our Balbriggan Booking Clinic please complete the
details below and return by email and we will respond as soon as possible.
Name

Phone Number

Date of Birth

Medical History

Surgical History

Pregnancy
History

Medication
History
Last Menstrual
Period (LMP)
Current weeks
pregnant
Weight

Height

BMI
Additional Information required for registration:
1) What is your birth
surname?

2) What is your mothers birth

surname?

3) If married, what is your

date of marriage?

4) What is your partner’s

mothers birth surname?

5) What is your occupation?

(actual title- not self
employed)

6) What is your partners

occupation? (actual title- not
self employed)

7) What is your partners

nationality?

8) What is your current

address?

9) What is your next of

kin/partners address?

10) If doing combined care

with GP please provide
approx.. date of first visit to
GP………..