Client Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Name on Health Card (if different from above) First Name Last Name Health Card Number * Version Code * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Work Phone or Emergency Contact If applicable (###) ### #### Email * Partner's Name If applicable First Name Last Name Partners Phone Number If applicable (###) ### #### Family Doctor or Nurse Practitioner Name First Name Last Name Which pharmacy do you use? First Day of your last period If unsure, use best guess MM DD YYYY Estimated Date of Birth If unsure, leave blank MM DD YYYY Pregnancy Confirmed By: Home Test Urine Test Blood Test Have you had an Ultrasound? Yes No Do you have a future Ultrasound booked? If yes, when? INCLUDING this pregnancy, how many times have you been pregnant? * Including any terminations or miscarriages Number of children Please include year(s) born Previous Midwife If applicable Kelly Graff Bekkie Vineberg Have you had any previous pregnancy or birth complications? Midwifery is meant for low risk, healthy woman. Is there any reason to believe you would not fall into this category? Have you developed high blood pressure, diabetes, or a thyroid condition? Have you or will you consider a Home Birth? * Additional Information Anything you think might to helpful or useful for the Midwife to know. Medication/Medical Conditions/etc. Thank you! We will be in contact with you within one week.If you don’t hear from us within the one week please call the office to confirm your intake has been submitted.
