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 by phone or email, either offering you an initial appointment or asking if you would like to be placed on the wait list.

Initial Appointment:

Your first appointment will be 45 minutes with a midwife  at our clinic location. This appointment is an opportunity for you to decide if midwifery care is right for you. You are not accepted into care until after this appointment. Please continue care with your current physician or nurse practitioner until both yourself and the midwives feel that this is a good fit.

Accepted into Care:

If you have been offered a spot with one of our midwives, you will need to book another  appointment. This appointment will allow us to review your detailed medical history and discuss any lab work, ultrasounds or other testing you may choose to have.  Lab work, ultrasounds or other testing that has been ordered by your physician or nurse practitioner can be obtained with your permission.  All our appointments are 45 minutes.

Thank you, we look forward to meeting you!

New Client Form

1. Full Namerequired
2. Address
3. City
4. Province
5. Postal Code
6. Home Telephone Number
7. Cell Phone Number
8. 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. 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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