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Babease Midwifery

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

Clinic hours: Wednesdays 10am–7pm.
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.

There will be $50.00 registration fee per pregnancy at the first prenatal appointment! This is to cover extra services provided but not covered by the Medical Service Plan. If you have any questions please don’t hesitate to ask.

Initial appointments are done in the clinic on Wednesday’s from 10am – 7pm; please disclose preferred time and date.  The clinic is situated in the building just beside the Sea Bus Terminal at the Lonsdale Quay.

    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 Wednesdays 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.