Intake Please note that you do not need a referral for midwifery care. We will be in touch once we receive your intake form below.Name on Care CardCare Card NumberBirthdayAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePhoneAlternate NumbersLast Menstrual Period DateThe first day of your last menstrual period.Estimated Due Date (EDD)Your estimated due date based on your last menstural period date.Emergency Contact Name and NumberPartner’s NameFirstLastTell us your children's names, ages and any details about your previous birth(s) if applicable:How did you hear about us?You will have access to us by email for non-emergency purposes. Do you feel comfortable receiving emails in regards to scheduling and appointment reminders?YesNoEmail *Captcha * = CommentSubmit If you have any questions, you can email us here, or phone our clinic at: 604-820-2424