Contact Us

please contact us for more information

Babease Midwifery

Suite 370-145 Chadwick Crt.
North Vancouver, BC
V7M 2K1

Clinic hours: Mondays  & Wednesdays 9–5pm.
Tel:
(604) 983-0949 | Fax: (604) 983-0946

Client Intake Form

The intake form should only be filled out by the clients seriously interested in midwifery care.

The initial evaluation for the midwifery care is covered by BC Care Card, only if you enrol into care at the time of the initial appointment, otherwise the amount of  $60.00 is required. Please note that initial appointment may not necessarily guarantee enrolment into midwifery care.

Initial appointments are done in the clinic on Mondays from 9-5pm; please disclose preferred time and date.  The clinic is situated in the building just beside the Sea Bus Terminal at the Lonsdale Quay. There are two hours free parking at the Lonsdale Quay Market

Your First Name (required)

Your Last Name (required)

Your Address (required)

Street:

City:

Postal Code:

Telephone Number (required)

Your Email (required)

Your family Doctor's name and telephone Number (required)

Is your prenatal blood work and ultrasound done by your doctor? (required)
YesNo

Is this your first pregnancy?
YesNo If not, please check all that apply Vaginal delivery/iesCaesarean sectionMisscarriage

What is your LMP? (required)

Are your cycles regular (how many days) or irregular? (required)

Are you on any prescribed medication? YesNo If so, what is the name of the medication?

Expected Date of Birth? (required)

Do you have a BC Care Card? (required)
YesNo

What is your Care Card #? (required)

Date of Birth (year/month/date) (required)

Preferred Place of Birth (required)

Preferred Method of Birth (required)

Are you currently in care of a midwife or obstetrician? If so, please add their name: (required)

Preferred time on Mondays for your appointment? (required)

How did you hear about us? (required)

Please type the letters:
captcha

*Please double check if your e-mail address is correct, otherwise you will have no response to this intake form.