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APPLY FOR CARE
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1240 14th Avenue SW, Calgary AB
Apply for Care
Please complete this form to apply for midwifery care with us.
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required
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Do you have Alberta Health Care?
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Preferred name (if different than legal name)
What was the first day of your last menstrual period?
Do you or your partner identify as Indigenous?
Choose an option
What are your Preferred Pronouns?
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Where do you plan to have your baby?
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Number of pregnancies (including current pregnancy, miscarriages and losses)
How many babies have you given birth to?
At what gestational age were your previous babies born?
How many cesarean births have you had?
Have you had any complications with your current and/or previous pregnancies, deliveries, or losses? (For example: postpartum hemorrhage or abnormal bleeding, breech, vacuum or forceps delivery, gestational diabetes, high blood pressure, etc...)
Do you see a doctor or specialist for any other health condition? (Ex. high blood pressure, diabetes, heart conditions etc...)
Please list any medications you are currently taking inlcuding dosages.
What was your pre-pregnancy weight?
How tall are you?
Please provide your partner's full legal name, if applicable (as it would appear on your baby's birth certificate)
Please provide your partner's date of birth, if applicable (as it would appear on your baby's birth certificate)
Have you had midwifery care before?
If you are offered an initial visit, do you consent to your midwife accessing your existing lab results and ultrasounds prior to your first visit?
Is there anything you would like us to know about you or your family before your first visit?
Submit
Thank you for applying!
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