# The Social Security (Medical Evidence) Regulations 1976, Part II: FORM OF CERTIFICATE


MATERNITY CERTIFICATE
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 than 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 NMC Personal Identification Number and the expiry date of your registration with the NMC.
Date of signing ......./........../........
___________________________________
Signature:
Doctors:
Please stamp your name and address here (unless the form has been stamped, in Wales, by the 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)

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Source: https://www.legislation.gov.uk/uksi/1976/615/schedule/2/part/II (the official version)
Page: https://openlegislation.uk/social-security-medical-evidence-regulations-1976/schedule-2/part-II
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.