Application Form

We thank you for your interest in midwifery care!

If you are pregnant and interested in midwifery care, please complete and submit the form below. All information provided is secure and confidential. Once we receive your application, we will contact you directly by email or phone, as soon as we have determined whether we can offer you midwifery care.    

Sincerely,
Mighty Oak Midwives

 

  • New Client Form

  • Please tell us the name you prefer us to use when addressing you and your preferred pronoun ~ for example; "he" "she" or "they" (or another not listed).
  • Full name as it appears on your BC Care Card. We will contact you later for your BC Care Card number.
  • Please provide the number to best contact you.
  • Please provide an alternative method to reach you.
  • You will receive email confirmation of your application (please note that hotmail users may not receive the confirmation email due to spam filters).
  • PO box or rural route? Please include your physical address!
    Midwifery services are not covered under out of province medical plans.

  • Personal Details

  • Select date DD slash MM slash YYYY
  • Select date DD slash MM slash YYYY
    Have you experienced any complications of pregnancy or birth? If yes, please describe in "medical concerns" below.
  • Please list ALL medical conditions, medications, special needs or medical history that may impact your care. If no medical concerns, please enter "none" in the text box above.
  • Please tell us why you would like midwifery care?
  • Is there anything else that you would like to tell us?
  • Personal or professional referral? Let us know who, so we can say thank you!
  • This field is for validation purposes and should be left unchanged.