INTAKE FORM — Chinook Midwives

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ABOUT MIDWIFERY

CHOICE OF BIRTHPLACE

ABOUT MIDWIFERY

CHOICE OF BIRTHPLACE

ABOUT MIDWIFERY

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CHOICE OF BIRTHPLACE

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To apply for midwifery care, please apply here or complete the form below.

Congratulations on your news!

In Alberta, families choose either a Midwife or a Physician for their maternity care.

To apply for midwifery care, please complete this form. The form may not work from your cell phone / tablet. Please apply from a laptop or desktop.

Do you have Alberta Healthcare

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Email *

Street Address *

City *

Postal Code *

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

Have you ever had a caesarean delivery? *

Yes

No

Due Date *

MM

DD

YYYY

Have you had care from Chinook Midwives before? *

Yes

No

Preferred Midwife *

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)

Comments *

Thank you!