Registration

The first step is to know more about you. Please fill the following form carefully. We value your privacy so all these information will be highly confidential.

Registration Form

Fields with (*) are required

First Name (as appears on your health card) *
Last Name (as appears on your health 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
Your Partner's Phone *
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? *
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?

Verification

Please enter any two digits *Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:

Registration Form

Fields with (*) are required

Verification

Amazing

Highly recommended

Caring midwife

Caring & loving midwife