Northern Midwifery Care - Client Intake Form
Northern Midwifery Care - Comprehensive care for the North since 2004
 

NMC Client Intake Form

You may choose to fill out this online form which will provide us with all the information we need to start your client chart, or to call our office at 250-562-0834. Your information will be reviewed and we will get back to you within 48 hours to advise you whether there is space available. Please be assured that your information will be kept confidential.
Your Name:(Required)
If you have a partner what is his or her name?
Email Address (required)
Your Address:*
Best number to reach you at: *
Date of Birth *
CareCard Number (if possible)
When is your baby due? (required)
When was your last menstrual period? (if known) And how long were your cycles (if known)
Is this your first baby? *
If this is not your first baby what type of births have you had?
Vaginal Birth
Cesearean Section
Vaccum or Forceps
Have you had any pregnancy care yet?
We offer you choice of birth place. Do you have an initial preference?
NMC believes working in collaboration with Doula's in our community provides optimal care for clients. *
I am interested in collaborative care with a doula
I am unsure about Doula care, please tell me more!
I do not want a Doula involved in my care
Describe any pre-existing health conditions or pregnancy complications that may affect your care:
Do you know anyone who has care from NMC? If so who?
How did you hear about the care NMC provides?
Is there anything else about yourself or your health you would like us to know? Feel free to let us know what interests you about midwifery care.
If we don't currently have room to take you on as a client, would you like us to keep your name on our waiting list in case a spot opens up in the near future?
Yes
No
We treat the information gathered on Intake Forms with strict confidentiality. However, with your permission, if we don't have room to take you on as a client, we can provide the College of Midwives of BC with your initials and postal code as a way of demonstrating the need for more midwives in the province. In turn, the CMBC would keep your name confidential and only release overall statistics without identifying information.
Yes, you can give this info to the CMBC
No, please do not release this info to the CMBC
Thank you for your interest in becomming a client with NMC

 
Thank you, we look forward to meeting you and your family!
 
Website Builder provided by Vistaprint