Cook Street Community Midwives Clinic

101-1005 COOK STREET, VICTORIA BC, V8V 3Z6

We encourage you to complete this intake form to assist us in finding a midwife available for your due date and pregnancy care needs.

Please note we have had technical issues recently receiving some intake forms filled out on mobile phones; use a computer if possible. If you do not receive a confirmation message after submitting the form, please follow up by email.

PHONE

250 386 4116

FAX

250 386 4122

EMAIL

cookstmw@gmail.com

Name as it appears on BC medical card (care card)

First Name

Last Name

Preferred name and pronouns

Do you have a partner(s)? If so please share their name(s), phone numbers, and pronouns.

Phone

(###)

###

####

Date of Birth

YYYY

Address

When was the first day of your last menstrual period?

YYYY

Estimated Due Date (if known)

YYYY

Have you given birth before?

Do you have any health concerns? If applicable, how were your previous pregnancies and births?

Are you currently receiving pregnancy care or have you had any labwork or ultrasounds done so far in this pregnancy?

Have you had care at our clinic before?

Is there anything else you would like us to know?

Intake Form

Cook Street Community Midwives Clinic

101-1005 COOK STREET, VICTORIA BC, V8V 3Z6

PHONE

FAX

EMAIL

VISIT US

CONTACT US

101-1005 Cook Street
Victoria, BC, Canada
V8V 3Z6

Phone: 250 386 4116
Fax: 250 386 4122

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