Print

Early pregnancy loss recognition certificate

We offer our condolences for your loss.

To recognise your loss, you can apply for a free recognition certificate—there are 2 designs for you to choose from. You can't use the certificate for official purposes.

If your delivery took place after 20 weeks, you will need to register the birth.

How to apply

We are not able to register the birth but you do have the right to commemorate your family’s loss—if your baby was delivered before 20 weeks gestation or, if weeks are unknown, weighed less than 400g.

It will take you about 10 minutes to complete this application form.

Step 1—Fill out online

1. Answer the questions below.
2. Review your details.
3. Download and print your completed application form.

Step 2—Complete on paper and submit

4. Have your treating medical practitioner or midwife to sign the declaration on the application form.
5. Submit your signed application form to us either:
   1. by post to Registry of Births, Deaths and Marriages, PO Box 15188, CITY EAST QLD 4002
   2. in person at the Brisbane registry customer service centre at Level 32, 180 Ann Street, Brisbane.

1. Can I commemorate our family's early pregnancy loss?

   1. Did your loss take place in Queensland? *

      • Yes
      • No
   2. Did your loss take place before 20 weeks—or, if weeks are unknown, your baby weighed less than 400g? * (If you chose 'Yes' above)

      • Yes
      • No
   3. Is your treating medical practitioner or midwife available to sign the declaration? * (If you chose 'Yes' above)

      • Yes
      • No
   4. By using this online service and providing an email address and mobile number, I consent to the use of that email address and mobile number for the Registry of Births, Deaths and Marriages (RBDM) to contact me via SMS and email that relates to this application. I understand that it is my responsibility to ensure that I have nominated a secure email address for RBDM to send any related correspondence to. I acknowledge that it is my responsibility to ensure the security of that information upon receipt of it.
2. Fill in your application form Fill in the application and have it signed before submitting it.

   1. The design I would like *

      • Flower
        
      • Candles
        
   Baby's details
   If you choose not to provide a name the certificate will show—Baby of mother's name and father's (or parent's) name.
   1. Baby's name

      1. First name
      2. Middle name(s)
      3. Family name
   2. We understand that due to the circumstances of your pregnancy loss you may not be able to give the following details.
   3. Place

      1. Town or city
      2. State *
   4. Date dd/mm/yyyy
   5. Gestation in weeks
   6. Weight of baby
   2. Mother's details

      1. Mother's name

         1. First name *
         2. Middle name(s)
         3. Family name *
      2. Age * In years
   3. Father's or parent's details

      Parent details are provided for same sex parents and your choice determines how your relationship is shown on your baby's recognition certificate.

      1. I am the baby's

         • Father
         • Parent
      1. Father's or parent's name

         1. First name
         2. Middle name(s)
         3. Family name
      2. Age In years
   4. Who is applying

      1. Relationship to baby *

         • Mother
         • Father
         • Parent
      2. Your postal address

         1. Address line 1 *
         2. Address line 2
         3. Address line 3
         4. 1. Town, city or suburb *
            2. State or territory *
            3. Postcode *
      3. Telephone number * Daytime number
      4. Mobile number *
      5. Email *
   5. Before I complete my application *

      • I will check the details I have provided.

   Remember

   You will need to submit your application signed by you and your health care professional to us by post or in person to finalise your application.

Our condolences for your loss

We're unable to commemorate a loss outside of Queensland. Contact the interstate or overseas registry.

You don't use this form

Please complete a birth registration application.

Our condolences for your loss

We're unable to issue you with a recognition certificate until the declaration has been signed.

Privacy notice
The Department of Justice and Attorney-General is collecting your personal information for the purpose of providing services and undertaking related activities. The information on this form may be provided to law enforcement agencies and to government and non-government agencies for verification of the data. Access to this information or a certificate may be granted to any person who has adequate reason to obtain it, or who meets the requirements of the access policy.

Contact us

Online: Our general enquiry form.

By phone: Local call* 13 QGOV (13 74 68)

International +61 7 3328 4811 (+10 hours UTC)

(Phone lines open Monday–Friday, 8.30am–4.30pm)

*Costs may be higher from mobile phones and interstate.