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Northern Midwifery Care
Your Name (Required)
If you have a partner what is his/her name?
Email Address (required)
Home Adress
Date of Birth
Care Card Number
Home Phone Number
Cell Phone Number
Have you had any care in this pregnancy yet?
Not Yet
Yes, Family Doctor
Yes, Walk in Clinic
Yes, an Obstetrician
Yes, another Midwife
Self Care
When is your baby due?
To confirm your due date, when was your last menstrual period?
Approximately how many days long are your menstrual cycles?
I don't know
Irregular
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
This is baby number
One
Two
Three
Four or more
NNCC offers collaborative care, & recommends involving a Doula to provide optimal care. This is optional, you only need to have a Doula involved if you choose.
I don't know if I would like Doula Care
I am happy to have collaborative care with a Doula
I would prefer not to have Doula care
I am a previous client & unsure about this option
Doula Services are not covered by our Medical Services Plan. Funding is available as needed, as NNCC believes nobody should be without Doula support due to an inability to pay.
I can afford to pay for Doula Care
I can afford to pay partial payment for a Doula
I cannot afford to pay for Doula Care
If funding is available I would like a Doula
I do not want Doula care
Do you know any Doula's that your would prefer?
No
Yes
I don't know
If you know which Doula you would like to work it what is her name?
How did you hear about Northern Natural Childbirth Collective?
Family Member
Friend
Past Client
Phone Book
Online
Advertising
Other
Any further questions, comments or information you would like to provide?
