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Registration Form

First Name (As appears on your care card) *
Last Name (As appears on your care card) *
Preferred name and pronouns
What is your date of birth? *Note: To do it faster first set day and month and click OK and then change the year manually.
Email Address *
Phone Number *
What is your BC Care Card Number? (PHN) *
Home Address *
Please list your buzzer number if you have one for your home address
If you have a partner, what is their name and phone number?
Estimated due date (if known) Note: To do it faster first set day and month and click OK and then change the year manually.
First day of your last menstrual period: *Note: To do it faster first set day and month and click OK and then change the year manually.
Do you have any major health conditions? *If Yes, please explain
What is your preferred choice of birth place? *You will register at a hospital regardless of if you plan to birth there or at home
Have you given birth before? *
YesNo
If you have, how many times and did you have vaginal births and/or cesarean sections? If it was with our practice, what year?
Have you had any losses?
YesNo
Do you have a family doctor? If so what is their name and office phone number?
Have you already seen a care provider who ordered blood work and/or an ultrasound?
YesNo
Other notes
Were you referred to a specific midwife by a previous client of ours? Do you have any unique needs we should know about? Do you plan to move during pregnancy? If so, where to?