INTAKE FORM

PLEASE FILL OUT THE INFORMATION BELOW TO SCHEDULE AN INITIAL APPOINTMENT WITH US.

Feel free to come talk about midwifery care and how we can support you and your family. We serve the entire Sunshine Coast, from Langdale, Gibsons, Roberts Creek, Sechelt, Halfmoon Bay, Secret Cove, Madiera Park and beyond. We have 2 clinics: one in Gibsons and one in Sechelt. If you’re not sure which one to go to, contact us and we will book you into the right one. If you are seeking a visit for lactation support from an IBCLC, simply fill out the relevant boxes. We are family-centred, so please bring your partner, children and/or anyone else you want to join you!

Name

First Name

Last Name

Pronouns

Phone Number

Address (including Postal Code)

Date of Birth

Do you have a BC Medical Care Card?

Please enter your BC Medical Care Card number if you have it

How did you hear about us?

Google Search

Word of Mouth

Website

Other

Are you seeking Midwifery Care or a Lactation Consult

Please enter the date of your last menstrual period (if known)

Please enter your expected date of delivery (if known)

We offer choice of birth place. Do you know which you would prefer?

Message

Please let us know anything you would like us to know about yourself