Pregnancy Intake Form

First name *As it appears on your health card

Middle name

Last name *As it appears on your health card

Phone *

Email *

Date of birth *

BC Care Card / PHN *Personal Health Number (Medical Services Plan)

Height *

Weight *

Street address *

City *

Postal code *

Partner's name *

Estimated due date *

First day of your last menstrual period *

Major health conditions *

Are you on any medication? *

Preferred place of birth *

Have you given birth before? *

Do you have a family doctor? *If so, please share their name and office phone number

Have you already seen a care provider in this pregnancy? *Someone who ordered blood work and/or an ultrasound

Who is your obstetrician, midwife, or maternity doctor for this pregnancy? *

* Required fields. Your information is kept confidential.