Welcome to Cowichan Midwifery Collective!

If you would like to request care from us, please complete and submit the intake form below. Please complete as much or as little as you feel comfortable.

If you prefer you can also call our office and at 250-748-8088 and speak to our staff.

Current Date *
Current Date
Contact Information
Name *
Name
Partner's Name
Partner's Name
If you have a partner in this pregnancy, please provide their name.
Home Address
Home Address
Mailing Address
Mailing Address
Please provide your mailing address if different from your home address.
Home Phone Number *
Home Phone Number
Work Phone Number
Work Phone Number
Cell Phone Number
Cell Phone Number
What's the best way to reach you? *
Pregnancy Information
Is this your first baby?
Have you had midwifery care previously?
Estimated Delivery Date (if known)
Estimated Delivery Date (if known)
First Day of Last Menstrual Period (if known)
First Day of Last Menstrual Period (if known)
If you are uncertain about your estimated due date or the first day of your last menstrual period, please describe your cycle here. Otherwise, this is a great opportunity to tell us more about this pregnancy!
Give us a short description of what what your previous pregnancies and births were like? Any complications or concerns? We will review this information with you when we see you in the office.
Other Information
If yes, please provide their name.
Do you have a BC MSP Care Card?
Please provide the name exactly as it's written on your Care Card.
What is your date of birth?
What is your date of birth?
Is there anything else you would like us to know before your first visit?
 

*Midwives are committed to confidentiality.  We keep your personal information private and it will never be released without your permission.