Client Registration

Midwifery care is self-referred. You do not need a referral to request space with a midwife.

In order to match you with a suitable team of midwives, we would like to learn more about you.

Please fill out this online form, and our Office Administrator will contact you by phone or email.

Name (as appears on your health card)

First Name

Last Name

Preferred name and pronouns

Email Address

Cell phone number

Postal Code

Please note that we prioritize Vancouver area clients. If you live out of area and want to find Midwives in your community please go to bcmidwives.ca

If you have a partner, what is their name and phone number?

Estimated due date (if known)

YYYY

First day of your last menstrual period:

YYYY

Do you have any major health conditions?

What is your preferred choice of birth place?

You will register at a hospital regardless of if you plan to birth there or at home.

Have you given birth before?

Yes

If you have, how many times and did you have vaginal births and/or cesarean sections? If it was with our practice, what year?

Have you had any losses? (miscarriage, termination, pregnancy or infant loss)

Yes

Do you have a family doctor? If so what is their name and office phone number?

Have you already seen a care provider who ordered blood work and/or an ultrasound?

Yes

Are you seeking a provider who is Black, Indigenous, or a Person of Colour?

Other notes

Were you referred to a specific midwife by a previous client of ours? Do you have any unique needs we should know about? Do you plan to move during pregnancy? If so, where to?

Online registration form

Midwifery care is self-referred. You do not need a referral to request space with a midwife.

In order to match you with a suitable team of midwives, we would like to learn more about you.

Please fill out this online form, and our Office Administrator will contact you by phone or email.

Thank you for your interest in Pacific Midwifery. We look forward to meeting you.