New Patient Postpartum Intake Form

Congratulations on your pregnancy!

We look forward to welcoming you to our practice for postpartum care. We collect this information to assist us in preparing to provide you with the best possible care for your postpartum period. Please tell us as much or as little as you feel comfortable. We recommend you use Google Chrome as your browser when completing this intake form as we have had issues with other browsers not sending the form correctly to us for triaging. If you do not hear from us within 1 week, we recommend you fill in this form again to ensure it has been received.

We also offer a prenatal infant feeding class, to help you prepare for feeding your baby, breast/chest or however you choose. For more information, click here.

If you are looking for the Prenatal Intake Form, please click here.

What to expect at your first visit

You will have a 30-45 minute visit with one of the midwives on our postpartum team. During this visit, they will discuss with you what to expect from postpartum midwifery care, answer your questions, and plan how we can best support you and your family.

All information provided remains private and confidential.

* required fields

Name (as it appears on care card)

First Name

Last Name

The name and pronouns you use

Do you identify as Indigenous?

Email Address (pls check junk folder)

Phone

Primary support person/emergency contact phone and their pronouns

Address

City, Province

Postal Code

Who will be your main support person/people during your pregnancy?

Do you have other children? If so, names, and ages of children?

If you have other children, where were they born (i.e. Canada? BC? Home? Hospital?)

What is your birth date? (yy/mm/dd)

Do you have a BC care card?

Yes

Waiting for one

What is your due date?

What hospital are you registered at?

Who is your care provider for this pregnancy?

Care Provider in this case refers to either OBGYN, GP, midwife, etc. A medical practitioner. Please include their name.

Do you have a family doctor? If so, what is their name and clinic name?

Are you generally healthy? Do you have any major health concerns? Are there any complications in your pregnancy?

How are you hoping to feed your baby when they are born?

Is there anything you would like us to know about you or your family before our first visit?

How did you hear about us?

I confirm I am looking for Postpartum Midwifery Care only.

This includes care after birth and up to 6 weeks postpartum. This DOES NOT include Labour and Delivery or Prenatal Visits aside from breastfeeding consultations.

Yes

Postpartum Care Intake

New Patient Postpartum Intake Form

Congratulations on your pregnancy!

What to expect at your first visit