Roundhouse Midwives client application form

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Please complete this form if you would like Roundhouse Midwives to provide care for your pregnancy. You are encouraged to register as early in pregnancy as you can, since we limit the number of clients we take each month. Our administrative staff will be in touch with you within 4-5 business days to confirm whether our practice can provide care for you.

Your full name (as it appears on your care card): *

Your preferred name:

Your preferred pronouns:

Your email address: *

Your date of birth: *

YYYY

Your phone number: *

Your full mailing address (including postal code): *

Your partner's name and phone number: *

Do you have an active BC Care Card?
*

Yes

No, I have military coverage

No, my BC Care Card is not currently active

No, I don't have a BC Care Card

Other:

If known, when is your estimated due date?

YYYY

What was the first day of your last menstrual period?

YYYY

How many days long are your menstrual cycles? (Average is 28 days)

Do you have any requests for which midwife/midwives you would like to work with? Please let us know if you are a previous client of one of our midwives.

If a previous Roundhouse client has referred you, please include their name.

Is there anything else you would like the midwives to know at this stage?

Have you had any previous pregnancies before?

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