# The Statutory Maternity Pay (Medical Evidence) Regulations 1987, Part II: FORM OF CERTIFICATE

Extent: E+W+S+N.I.

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 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 NMC Personal identification Number and the expiry date of your registration with the NMC . _________________
_________________
___________________________________
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 services performers list you are included).
______________________________

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Source: https://www.legislation.gov.uk/uksi/1987/235/schedule/part/II (the official version)
Page: https://openlegislation.uk/statutory-maternity-pay-medical-evidence-regulations-1987/schedule/part-II
Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives.