Cook Street Community Midwives Clinic

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

250 386 4116

250 386 4122

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

(###)

###

####

BC Care Card Number

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