Are You Looking for a Midwife?

Please fill out our on-line intake form below, or call our office at 250-900-3770.

Thanks!

Your name *

First

Last

What is your preferred pronoun?

If you have a partner, what is their name?

First

Last

What is your partner's preferred pronoun?

Street address *

Street address line 2

City *

State/Province

Postal/Zip Code

Email *

Cell phone *

Is it okay for us to leave a voicemail? *

Home phone

Partner's phone

Your birth date *

When was the 1st day of your last menstrual period?

What is your expected due date? *

Approximately how many days are your menstrual cycles?

From the first day of your period to the start of your next period. e.g. 28 days

Is this your first baby? *

If applicable, please describe your previous pregnancy and delivery experience.

How are you feeling in your pregnancy so far?

What is your family doctor's name?

Your height?

Your pre-pregnancy weight?

How would you describe your health?

Do you wish to identify as BIPOC (Black, Indigenous, Person of Colour), or as someone who has recently arrived to Canada?

If possible, we try and reserve spaces for BIPOC clients, and/or folks newly arrived to Canada.

How did you hear about Arbutus Midwives