Current Date (MM/DD/YYYY) *

MM

DD

YYYY

Name *

First Name

Last Name

Partner's Name

If you have a partner in this pregnancy, please provide their name.

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

Please provide your mailing address if different from your home address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number *

(###)

###

####

Work Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

What's the best way to reach you? *

Home Phone

Cell Phone

Work Phone

Is this your first baby?

Yes

No

Have you had midwifery care previously?

Yes

No

Please indicate if you have a preferred midwifery team. Although it is not always possible we will try to accommodate your request.

Selina Boily and Chloe Markgraf

Jenny Jackson and Lydia Pedri

Estimated Delivery Date (if known). (MM/DD/YYYY)

MM

DD

YYYY

First Day of Last Menstrual Period (if known). (MM/DD/YYYY)

MM

DD

YYYY

Do you have a BC MSP Care Card?

In order to protect your private information, we ask that you call or email your Care Card number so we can complete your intake.

Yes

No

Applying for one

What is your date of birth? (MM/DD/YYYY)

MM

DD

YYYY

Cowichan Midwifery Collective is a thriving midwifery practice committed to quality care. To maintain this commitment we limit the number of individuals we care for. Please indicate if you would like to be added to Cowichan Midwifery Collective's waitlist.

Please add me to Cowichan Midwifery Collective's waitlist and notify me if a spot becomes available.

To assist individuals looking for midwifery care in a timely manner, the Cowichan Valley midwives also have a shared waitlist which requires collection and sharing of limited personal data with other midwifery practices in the Cowichan Valley. Please indicate if you would like to be added to this waitlist and contacted by the midwifery practice with the next available opening.

Please add me to the SHARED Cowichan Valley waitlist.

I consent to sharing my name, contact information and estimated due date with the other midwifery practices in the Cowichan Valley. *