Ask for a MidwifeApply for Midwifery care services here: Personal Information Name * First Name Last Name Email * Address * City * Postal Code * Phone Number * Is it ok to leave messages on your voicemail? Yes No Birthdate * MM DD YYYY Health Information Do you take any prescription medications? * Yes No If yes, please list them here: Do you see any specialists on a regular basis for serious or chronic medical conditions? If yes, please list them here: Do you have or have you had any of the following medical conditions in the past: * Heart problems or Heart disease High Blood Pressure Kidney or Liver Problems Epilepsy or other neurological disease HIV positive status Bariatric surgery Thyroid problems Blood clots or pulmonary embolism None of the Above Current Pregnancy When was the first day of your last menstrual period? MM DD YYYY Do you have regular menstrual cycles? Yes No Due Date (if you know already) MM DD YYYY Have you seen a care provider in this pregnancy already? Yes No Where do you plan to have your baby? Home Hospital Not Sure Past Pregnancies How many times have you been pregnant? * How many vaginal births: * How many caesarean births: * Have you had a midwife before? * Yes No Partner Information (If Applicable Partner's Name First Name Last Name Other Information How did you hear about us? Do you have any questions for the midwife? Thank you for applying for care! We have placed you on our waitlist for care. We process our waitlist applications twice monthly. PLEASE NOTE: Due to volume of requests, we are only able to contact those clients for whom we have space available. Sincerely, the Midwives of Medicine Hat
