New Application Form - Mighty Oak Midwifery

New Client Form

First Name*

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 Legal Name*

Full name as it appears on your BC Care Card. We will contact you later for your BC Care Card number.

Daytime Phone*

Please provide the number to best contact you.

Seondary Phone

Please provide an alternative method to reach you.

Email Address*

You will receive email confirmation of your application (please note that hotmail users may not receive the confirmation email due to spam filters).

Home Address*

Street Address Address Line 2 City Province Postal Code

PO box or rural route? Please include your physical address!

BC Care Card*

Yes, I have a valid BC Care Card
No, I am applying for one now.
No, I am interested in private pay service.

Midwifery services are not covered under out of province medical plans.

Personal Details

Your Age

Occupation

Do you or your partner identify as First Nation, Metis or Inuit?

Husband or Partner's Full Name

Partner's Occupation

Family physician or nurse practitioner*

Pre-pregnant Weight*

Height*

First day of last mentrual period (LMP)

Estimated due date*

Will this be your first baby?*

Yes, this is my first baby!
Prior Vaginal Delivery
Prior Cesarean Delivery

Prior Complications?*

Yes
No

Have you experienced any complications of pregnancy or birth? If yes, please describe in "medical concerns" below.

Previous midwifery care?

Yes
No

If you answered yes, please tell us who your midwife / midwives were and, if local, whether you would like the same midwife (if available)

Please tell us a little about your previous birth experiences:

Medical Concerns*

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.

Health Factors

I exercise regularly
I smoke cigarettes
I am Vegetarian/Vegan

Why midwifery care?

Please tell us why you would like midwifery care?

Where would you prefer to deliver your baby?

Undecided
Home
Hospital

Comments

Is there anything else that you would like to tell us?

How did you hear about us?

Personal or professional referral? Let us know who, so we can say thank you!

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Name

This field is for validation purposes and should be left unchanged.