Northern Midwifery Care - CLIENT INTAKE FORM

Pregnant? Congratulations!

If you are interested in Northern Midwifery Care, please submit the following form. You can also call the office at 250-596-0834 or email Jane.


Northern Midwifery Care
Your Name (required)
Email Address (required)
Home Phone Number
Have you had any care in this pregnancy yet?
When is your baby due?
To confirm your due date, when was your last menstrual period?
This is baby number
NMC offers the option of collaborative care, with a doula to provide optimal care. This is optional--you may choose to add a doula to your birthing team or not--it is up to you. I would like more information about this option I am interested in collaborative care with a doula I don't know if I would like doula care I am a previous client & unsure about this option
Doula Services are not covered by our Medical Services Plan. NMC believes nobody should be without doula support due to financial concerns and has recieved funding for those who need it (no questions asked).
If you know a doula that you would love to include as part of your birth team, what is her name?
How did you hear about Midwifery care?
Any further questions, comments or information you would like to provide?

Thank you!