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Fillable Form Pregnancy Verification Letter

The pregnancy verification form is a letter that is used to show proof of a positive pregnancy test, confirming that the woman is indeed pregnant.

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What is a Pregnancy Verification Letter?

A Pregnancy Verification Letter or also referred to as a Pregnancy Verification Form or Proof of Pregnancy Letter is used by obstetricians, gynecologists, or local health department officials to verify that their patients have received a positive pregnancy test.

A patient may want to determine if she is pregnant or not if she experiences common symptoms of early pregnancy. Early pregnancy symptoms a woman may experience include but are not limited to the following:

  • Nausea with or without vomiting
  • Breasts getting tender or swollen
  • Missing a menstrual period or having a late menstrual period
  • Constantly feeling very tired
  • Constantly feeling bloated
  • Frequent urination due to hormonal changes and increased blood flow through the kidneys
  • Mood swings
  • Experiencing dizziness
  • Getting frequent headaches
  • Experiencing constipation
  • Having an increased sense of smell
  • Having frequent food cravings or certain aversions
  • A sudden rise in body temperature

For a woman to confirm if she is pregnant or not, she must take a pregnancy test. A woman can either go to an obstetrician or gynecologist to take a blood or urine pregnancy test and take a physical exam. She can also take a home pregnancy test kit which she can use herself.

The human chorionic gonadotropin (HCG) hormone is produced primarily by syncytiotrophoblastic cells of the placenta during pregnancy. This hormone will be present just a few days after a woman becomes pregnant. A pregnancy test is made to detect the human chorionic gonadotropin (HCG) hormone in a woman’s blood or urine.

At the early stages of pregnancy, a woman’s hormone levels will be low, but as time passes, these hormone levels will gradually increase. If a woman shows high levels of the human chorionic gonadotropin (HCG) hormone, that may be signaling multiple pregnancies. This means a woman may be giving birth to twins or triplets.

If a woman decides to take home a pregnancy test kit, she must expect to get inaccurate results. For a woman to get an accurate pregnancy confirmation, she must follow the manufacturer’s instructions strictly without missing a single step. Most home pregnancy test kits follow similar instructions which may include but are not limited to the following:

  1. After a woman collects her urine using a small, clean container, she must dip the test strip in the urine. Some home pregnancy test kits may offer a test strip which can be held under a woman’s stream of urine.
  2. A woman may be able to get much more accurate results if she tests her urine right after she wakes up and gets out of bed. Early morning urine is concentrated and contains much higher levels of human chorionic gonadotropin (HCG) compared to other times of the day, that is why it is much more accurate.
  3. Most of the test strips in home pregnancy test kits determined the presence of human chorionic gonadotropin (HCG) by showing the appearance of a colored line or a simple dot.
  4. Most home pregnancy test kits take only a few minutes to complete. A woman can get the results almost immediately.
  5. Most home pregnancy test kits contain a secondary test strip just in case a woman may want to test her urine again at a different time.

There may be times when a woman can get positive pregnancy results even though she is not pregnant. Some of the reasons for false-positive results may include but are not limited to the following:

  • The urine collecting cup may be unclean
  • The pregnancy test kit could be faulty
  • There is blood in her urine
  • There is protein in her urine
  • Recent birth or miscarriage
  • The presence of an ovarian tumor

After confirming a woman’s pregnancy using a blood or urine pregnancy test, she may opt to get an abdominal or transvaginal ultrasound scan. A transvaginal ultrasound scan is used to create images of the inside of the body by using high-frequency sound waves or echoes. An ultrasound scan will not cause a pregnant woman harm since it does not use radiation. A transvaginal ultrasound scan can confirm the development of the fetus, the gestational age of a woman’s pregnancy, how many embryos there are, and if the placement of the fetus is correct in the womb of the woman.

A doctor may be able to determine a pregnant woman’s estimated date of delivery (EDD) by looking at the gestational age, which he or she can measure by counting the pregnancy from the first day of the woman’s last menstrual period.

A complete Pregnancy Verification Letter must include the following information:

  • Current date
  • Date of the pregnancy confirmation
  • Full legal name of the patient
  • Gestational age of the patient’s fetus
  • Patient’s estimated date of delivery (EDD)
  • Additional information about the patient’s condition and her pregnancy
  • Signature of the obstetrician, gynecologist, or local health department official
  • Date when the letter was signed

How to fill out a Pregnancy Verification Letter?

Get a copy of Pregnancy Verification Letter template in PDF format.

An obstetrician or gynecologist can write a Pregnancy Verification Letter for the patient or download a PDF copy from a website that offers document templates. For convenience, an obstetrician or gynecologist can also fill out the Pregnancy Verification Letter electronically on PDFRun.

To fill out the Patent License Agreement, you must provide the following information:


Enter the current date.

Date of Pregnancy Confirmation

Enter the date when the pregnancy of the patient was confirmed.


Enter the day when the pregnancy of the patient was confirmed.


Enter the month when the pregnancy of the patient was confirmed.


Enter the year when the pregnancy of the patient was confirmed.

Name of Patient

Enter the full legal name of the pregnant patient.

Gestational Age of Fetus

Enter the current gestational age of the patient’s fetus.

Estimated Date of Delivery (EDD)

Enter the patient’s estimated date of delivery (EDD) based on the date of her last menstrual period.


Enter the day of the patient’s estimated date of delivery (EDD).


Enter the month of the patient’s estimated date of delivery (EDD).


Enter the year of the patient’s estimated date of delivery (EDD).

Additional Information

Enter any additional information about the patient and her pregnancy.

Signature of Local Health Department Official

Affix your signature.

Date Signed

Enter the current date of signing.

Start filling out a Pregnancy Verification Letter sample and export in PDF.


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