Client Intake Form

Your full name (as seen on your care card):

Your preferred pronouns:

Your BC care card number:

Your email address:

Your address:

Street:  

City:  

Postal Code: 

The best phone number to reach you at:

Is it ok to leave a message? YesNo

Your partner's name and contact number:

Your date of birth:

Your age at your estimated due date:

The first day of your last menstrual period:

Your estimated due date:

Any previous deliveries? YesNo

If yes, please provide some details (dates, type of delivery [spontaneous, vacuum, forceps, C-Section], any complications, doctor or midwifery care, etc...)

Any significant medical conditions or ongoing medications? YesNo

If yes, provide a brief outline

What is your COVID-19 Vaccination Status?

Fully vaccinated - 2 doses of a Health Canada-approved vaccineBoosted - 2 doses of a Health Canada-approved vaccine plus a booster shotPartially vaccinated - 1 dose of a Health Canada-approved vaccineNot vaccinatedI choose not to disclose my vaccination status

*Note that Health Canada has approved the following vaccines:

• Moderna Spikevax

• Pfizer-BioNTech Comirnaty

• AstraZeneca Vaxzevria

• Janssen (Johnson & Johnson)

Please provide your Family Physician's name and phone number (or walk in clinic):

Have you had any ultrasounds, blood work or prenatal genetic screening done for this pregnancy? YesNo

If yes, please specify location, date and who it was ordered by.

How did you hear about our office?

FriendFamilyPhysicianWebsiteMABC/CMBCOther

If referred by a friend, family or physician, please let us know who to Thank!