Client Intake Form

Congratulations on your pregnancy!!

If you are interested in becoming a client at our clinic, please fill out the questionnaire below.  We review your information to determine if we have space available around the time you are due, and if we have space we can book a consultation visit.

Please provide the following information:

    1. Your full name (as seen on your care card):
       
    2. Your BC care card number:
       
    3. Your email address:
       
    4. Your address:
      Street:  
      City:  
      Postal Code: 
    5. The best phone number to reach you at:
       

      Is it ok to leave a message? YesNo

      Your partner's name and contact number:

    6. Your date of birth:
    7. Your age at your estimated due date:
    8. The first day of your last menstrual period:
    9. Your estimated due date:
    10. 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...)

    11. Any significant medical conditions or ongoing medications? YesNo

      If yes, provide a brief outline

    12. What is your COVID-19 Vaccination Status?
      Fully vaccinated - 2 doses of a Health Canada-approved vaccinePartially 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)

    13. Please provide your Family Physician's name and phone number (or walk in clinic):
    14. 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.

    15. How did you hear about our office?
      FriendFamilyPhysicianWebsiteMABC/CMBCOther

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

    Please note:  we will contact you within seven to ten business days to let you know if we have space and can book a consultation appointment for you.