Intake Form

Name (as it appears on care card) *

First Name

Last Name

Do you have a BC care card?

MSP covers the costs of midwifery care.

Yes

No, and I have no plans to apply

I have applied for one, it is awaiting activation

I have not yet applied but plan to apply

If you do not have a BC care card, are you prepared to pay privately for midwifery services?

Exact fees and payment schedule can be discussed with your midwife during intake.

Yes, I am capable of paying fully for services

Yes, I am prepared pay but might need adjustments

No, I will need pro-bono care

Do you require an interpreter?

Yes

No

Have you had care from another care provider in this pregnancy?

No

Family Doctor

Obstetrician

Midwife

What care have you had to date?

Bloodwork

Ultrasounds

Both

Neither

Do you see a care provider on a regular basis

Yes

No