Client Intake Form

If you are interested in becoming a client please complete the following intake form and click on the "submit" button. Due to demand, space may be limited and care is not guaranteed.

Your Name:

Your Email Address:

Your Phone Number:

Your Full Mailing Address:

Are you planning on moving during your pregnancy?
Yes: No:

If yes, which neighbourhood will you be living in when your baby is due?

Have you had a baby before?
Yes: No:

If so, was it a vaginal birth?
Yes: No:

Team Preference:

Due Date

Where would you like to have your baby?

Do you have any medical concerns that require you to see a medical doctor on a regular basis?
Yes: No:

Do you take any prescription medications?
Yes: No:

If you answered yes to either, please briefly elaborate (all responses are confidential)

Please provide us with a brief comment about why you are interested in midwifery care:

Birth Partnership Midwifery Services	Phone: 403.246.8968 \| Fax: 403.686.7720	6628 Crowchild Trail, SW Calgary AB T3E 5R8