Open Door Midwifery

Personal Information
Name * First Last
If you have a partner, what is his or her name? First Last
Where do you live? *
Home Phone ### - ### - ####
Cell Phone ### - ### - ####
Email *

We will not share your email address.
Date of Birth MM / DD / YYYY
Do you have MSP (a BC Care Card)?
Yes No I'm waiting for it
Enter your name as it appears on your MSP card. First Last
Your Pregnancy and Health
Have you given birth before?
No, this will be my first time Yes, I have given birth once Yes, I have given birth twice Yes, I have given birth three or more times
If you have given birth before, please tell us about your previous birth(s):
I've had one or more vaginal birth(s) I've had one or more cesarean birth(s) I've had both vaginal and cesarean births
Do you know the first day of your last period? If so, what was it? MM / DD / YYYY
When are you due? MM / DD / YYYY
Please tell us a little bit about your overall health. Do you have any significant medical conditions or health concerns?

If someone has told you or, if you wonder if you are too "high risk" for midwifery care, please come in and talk to us about it in an initial visit.
Midwifery Care
How did you hear about Open Door Midwifery?
Referral from family or friend Referral from other Care Provider I'm a past client I live in the area Internet Advertising Other
If a family member, friend or other Care Provider referred you to Open Door Midwifery, please tell us who it was:
Please tell us if you were referred to or, are hoping to meet with a specific midwife:
We offer choice of birth place. Do you have an initial preference?
Home Hospital I'm not sure yet
If you are planning a hospital birth, which hospital do you prefer?
BC Women's Hospital St. Pauls Hospital No preference or undecided
Is there anything else about yourself, your health or your pregnancy that you would like us to know? And, please feel free to tell us what interests you about midwifery care.
Do Not Fill This Out

Open Door Midwifery

Personal Information

Your Pregnancy and Health

Midwifery Care