Intake Form

Please fill out the form below and we will get back to you within 48-72 hours.

Your Full Name: (required)
Your Partner's Name:
Your Email Address: (required)
Your Phone Number: (required)
Your Address:
Are you in the Calgary or Canmore Area?:
Have you had a baby before?	Yes No
If so, was it a vaginal birth?	Yes No
Did you use a midwife?	Yes No
First day of your last normal menstrual period: (dd-mm-yyyy)
Estimated Due Date: (dd-mm-yyyy)
Where do you plan to have your baby?
Do you have any medical concerns that require you to see a medical doctor on a regular basis?	No Yes
Do you take any prescription medications?	No Yes
If you answered yes to either, please briefly elaborate (all responses are confidential):
Are you a smoker?	No Yes
Please tell us what appeals to you about midwifery care and any questions you may have for the midwives?