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:

  1. Your full name (as seen on your care card):
  2. Your BC care card number:
  3. Your email address:
  4. Your address (PLEASE PROVIDE YOUR FULL ADDRESS, including city, apartment or suite # and postal code):
    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, pregnancy loss or delivery, 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. Please provide your Family Physician's name and phone number (or walk in clinic):
  13. 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.

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

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

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Please note:  we will phone you within one week to let you know if we have space and can book a consultation appointment for you.