EmailMe Form - West Coast Health Collective Midwifery Intake

Name

What is your partners name?

Date of Birth

DD / MM / YYYY

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Confirm

Are you covered under BC's Medical Services Plan (MSP)?

Yes

No

Care Card/MSP Number

Name as written on card

First day of last menstrual period

DD / MM / YYYY

Cycle length

For example: 28 days (from beginning of period to beginning of next period)

When are you due?

DD / MM / YYYY

How many times have you been pregnant, including the current pregnancy?

How many living children do you have?

Were there any complications in your previous pregnancies and/or births?

ie. High blood
pressure, pre-eclampsia, diabetes, preterm birth etc.

Have you ever had a C-Section?

Yes

No

If yes, how many c-sections have you had and what were the reasons?

Would you like to plan another C-Section?

Yes

No

Unsure

*we offer services/support for all forms of birth

Are you looking for Postpartum care ONLY?

Yes

Height

Pre-pregnancy weight

Do you have any current or ongoing health problems that may impact pregnancy or birth?

ie. High blood pressure, diabetes, heart conditions, significant surgical history, seizures,
bleeding disorders etc.

We offer a choice of birthplaces. Do you have an initial preference?

Abbotsford Regional Hospital

Home

Undecided

Do you identify as someone in the BIPOC, LGTBQ, or any other marginalized community?

Yes

No

Prefer not to say

We strive to provide an affirmative, respectful and inclusive environment and hold space each month for someone in marginalized communities. We understand finding inclusive, safe, & respectful care can have additional challenges when trying to navigate your pregnancy, birth, and postpartum care.

How did you hear about us?

Please be specific.

Are you a previous client of one of our midwives?

Yes

No

If yes, which midwife/midwives?

Additional comments: