16 Free Pregnancy Verification Forms (Word | PDF)

A Pregnancy verification form is a document written by a medical expert as proof of positive results of a pregnancy test to verify that a woman is indeed pregnant and provide pertinent information related to the pregnancy.

Purpose and Overview

A pregnancy verification form details the date of the pregnancy test, the name of the attending doctor, clinic, or hospital visited, and any additional comments or notes related to the pregnancy. A pregnancy verification form keeps a record of the child’s development, thus assisting any future treatment of the expectant mother.

Pregnancy verification is not just a formality. There are legal and medical implications surrounding the crafting and use of a pregnancy verification form. A pregnancy verification form will serve distinct purposes for one’s patient. Below are some of the reasons why writing a pregnancy verification form for expectant mothers is important.

• The primary purpose, as mentioned earlier, is that the form acts as proof of a positive pregnancy test. This way, it represents the medical expert’s professional affirmation of the existence of the pregnancy meaning expectant mothers can use the form to disclose pregnancy to their employer and educational entity when applying for maternity leave. Expectant mothers use the form to take time off for routine check-ups.
• A pregnancy verification form is an essential document when expectant mothers claim health insurance for pregnancy from their insurer. A verification form helps expecting parents bypass the tedious and lengthy insurance claim investigations, for it is considered sufficient proof of pregnancy.
• The form helps keep track of the gestational age of the fetus throughout the pregnancy. Recording the results of the medical practitioner’s tests and the expectant mother’s medical history forms a basis for future medical examinations, tests, and treatment.
• A verification form also has legal importance. It can be produced in court while claiming inheritance, more so when the father passes away during the pregnancy. 
• A pregnancy verification form is a form of communication between medical experts. It provides details such as the expected date of delivery which is vital in gynecology and OBS (obstetrician) practice. 

Tip: verification of pregnancy is based on the two types of pregnancy tests; urine test and blood sample test.

The crafting of a formal and legal pregnancy verification form is governed by stringent rules and regulations, and consequently, it is advised that it should be prepared by a medical professional. With that cleared up, the form is customarily issued by a licensed medical expert responsible for tending to the expectant mother and the developing fetus. Gynecologists are the primary issuers of a pregnancy verification form. In addition, medical experts not registered as the official doctors of the expectant mother should not issue the verification form.

A proper pregnancy verification form should outline all the information required to care for the pregnant mother and fetus. With that in mind, writing a professional and informative verification form becomes less of an option. Doctors and medical facilities can opt to use a template or craft personalized verification forms. Preference notwithstanding, a standard verification form must have certain fundamental components. This article will look into these components as well as give a step-by-step guide in writing an up to standard pregnancy verification form below.

Parents information

First and foremost, the form should have a section for writing down information that can be used to identify the patient and her partner. Identifying the parents is important as it clarifies the persons being served by the verification form. The doctor writes down different identifying information. Such information includes;

• Parents’ names – The patient and her partner should be named. The name provided should match that provided in their official medical records to avoid confusion. This also makes it easy when medical experts are sharing medical information about the patient.
• Age – Indicate the age of the patient accordingly. Mentioning the age of the expectant mother in the form is important so as to ascertain that the woman has attained legal age. This way, medical experts are able to avoid legal issues or medical complications that would come if she has not come of age.
• Contact details – The form should then indicate contact information that can be used to reach out to the expecting patient or her partner. Contact information can be phone number, email address, and mailing address. The doctor can also include emergency contacts other than the partner’s contact information.

Note: Other personal information that medical practitioners can use when attending to the pregnant patient, such as weight, height, etc., can also be included.

Pregnancy symptoms 

The form should then outline the substantive symptoms the patient is exhibiting that suggest they might be pregnant. The doctor asks the patient if they have experienced any common symptoms of pregnancy and notes the down.

Examples of pregnancy symptoms include missed periods, nausea, tender and swollen breasts, increased urination, and fatigue.

Allergies

Afterward, the form should outline any allergies the expectant mother is allergic to. This includes medication. Indicating allergies is imperative for the safety of the mother and the developing fetus. When medical experts are presented with a list of the patient’s allergies, they are able to know what procedures and treatments to avoid.

Pregnancy details

The next component of a pregnancy verification form is details related to the pregnancy – more independent from the patient’s medical information. This section of the form should address the following;

• Estimated date of conception – The date of conception is the date when the baby was most likely conceived. The doctor should find out the estimated date of conception. The patient will often be more informed of this fact. However, simple calculations can be made or use conception calendar calculators if the patient is uncertain.
• Estimated date of delivery – The form should then indicate the date when the patient is most likely to give birth. Once the conception date is determined, estimating the date of delivery becomes easy. The normal gestation period is 266-270 days.
• Age of gestation – The physician should indicate how old the fetus is – how many weeks or months the woman is into her gestation period.
• The number of fetuses – The form should declare how many fetuses the expectant mother is carrying. It can be one, twins, triplets, etc.

The medical condition of the mother

After, the doctor should outline any maternal condition the expectant mother might be experiencing at the time of the examination. These medical conditions are any health condition in the expecting mother that poses a danger to the fetus or causes pregnancy complications.

The medical condition of the baby

The pregnancy form should then indicate the medical condition of the fetus. Fetuses can sometimes be found to have complications from sonograms and medical tests such as prenatal tests. If any condition has been identified, the doctor is obligated to indicate it in the verification form.

Examples of medical conditions, in this case, include spina bifida, congenital heart disease, etc.

Note: Medical conditions are updated throughout the gestation period.  

OB-Gyne information

The next section should address the birth plan developed between the patient and her Obstetrician and gynecologists.  The information that can be included in this section is preferred pain relief methods, routine exercise instructions, C-section (if necessary), and individuals the patient would like in the delivery room.

Additional information

Subsequently, the form should outline any additional information associated with the pregnancy. Additional information that can be included is marital status, applicable health insurance, or a list of documents that the patient must present to medical physicians for maternity or other medical needs.

Doctor’s note

The next component on the verification form is the doctor’s note. The doctor should include a doctor’s note to affirm that the patient had an appointment with them or the said medical facility. The note should show the date of the appointment and their recommendations. It should not be too detailed or descriptive, for the patient has a right to doctor-patient confidentiality.

Acknowledgment section

The last component is the doctor’s acknowledgment. An acknowledgment is essential as it declares the medical expert concurs with the content of the pregnancy verification form. Once signed, the acknowledgment implies that the doctor is a representative of the clinic or hospital where the patient was examined.

The acknowledgment becomes legally binding once the physician supplies their signature to it. The following information should then be provided.

• Doctor’s name – The doctor should indicate their official name as it appears on official records.

• Doctor’s Contact information – Contact information is important should their need for the doctor to be contacted. Including a phone number ensures the doctor can be contacted in case of a pregnancy emergency at work or school. Contact information should also include an email address.

Final Words

A pregnancy verification form is an essential document for one’s pregnant patient, for it allows them to prove their pregnancy to their employers or superiors when applying for maternity leave or travel needs. It should outline the patient’s details, her partner’s details, emergency contacts, allergies, pregnancy details, medical conditions of the mother and the baby, and other pregnancy-related details.  Pregnancy verification forms represent a doctor’s professional declaration of a woman’s pregnancy.