If you are pregnant and interested in midwifery care, please complete and submit the form below. All information provided is secure and confidential.   Once you have submitted your application form, we will contact you directly by phone or email within 7 – 10 days.

We thank you for your interest in midwifery care!
Sincerely,
Mighty Oak Midwives

New Client Form

1. First Namerequired
2. Last Name required
3. Street Address
4. City
5. Province
6. Postal Code
7. Home Telephone Number
8. Cell or Alternate Phone Number
9. Best time of day to reach you
10. morning afternoon evening
11. E-Mailvalid email required

Personal Details

1. Date of Bith
2. BC Care Card Number
3. Full Name as it appears on your BC Care Card:
4. What is your occupation?
5. Husband or Partner's Full Name
6. What is your partner's occupation?
7. Name of your family physician or nurse practitioner
8. Current Weight
9. Height
10. Where are you planning to deliver your baby? Undecided Home Hospital
11. First day of your last mentrual period (LMP)
12. Estimated due date, if known
13. Will this be your first baby?
14. Yes, this is my first baby! Prior Vaginal Delivery Prior Cesarean Delivery
15. Have you experienced any complications of pregnancy or birth? Please tell us about your experience:
16. Medical Allergies
17. Current medications, medical conditions, special needs or medical history that may impact your care
18. Please check all health factors that apply to you:||
19. I exercise regularly I am Vegetarian or Vegan I smoke cigarettes
20. Please tell us why you would like midwifery care?
21. Would you like to request a certain midwife?|| no preference Joanna Nemrava Rosalynd Curry Elaine Barnes
22. How did you hear about us?
23. In order to determine community demand for midwifery services and increase access to midwifery care across BC, we request your permission to provide your name to the College of Midwives of BC.
24. Yes, I support midwifery in BC! No, not at this time. Thank you.

 

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