Postpartum Intake – Aveta Midwifery

Please note that this is only for clients who require postpartum (post-delivery) care. If you are looking for care during your pregnancy, please go to our regular client intake form.

For health-care professionals making a referral, please make sure you select the correct Referral Type on the form.

Referral Type:

Client Self-ReferralGP/NP ReferralOB/Specialist Referral

Referring GP/NP/OB/Specialist:

Referring GP/NP/OB/Specialist's MSP#:

Does the client know about this referral and may we reach out to them?

Please fax Antenatal Records and Labour and Delivery Summary (if client has delivered) to 778-266-2016. If the client has already been discharged, please also include the Newborn 1 and Newborn 2 records along with any operative reports and consults related to the delivery.
Type of care:
Client Name:

Not delivered yet

BC Care Card# (Enter "000" for no care card):

Client Primary Phone#:

Client Date of Birth:

Client Email Address:

Preferred Pronouns:

Partner's Name:

Street Address:

City:

Postal Code

Buzzer Number:
COVID-19 Vaccination Status

*Note that Health Canada has approved the following vaccines:
- Moderna Spikevax
- Pfizer-BioNTech Comirnaty
- AstraZeneca Vaxzevria
- Janssen (Johnson & Johnson)
Any other children in the household?

First birth?

Twins?

NoYesTriplets

Estimated Due Date:

Date of Delivery:

Method of Birth:

Breastfeeding?:

Do you have a history of breastfeeding challenges?

Special and/or cultural considerations? Please elaborate below:
Other information such as ongoing medical concerns?