Midwifery Care Application
Thank you for your interest in Midwifery care. Please complete and submit this application.
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Email *
What is your name? *
What is your birthdate? *
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What is your occupation?
What is your age? *
Complete home address *
What brings you to midwifery care? *
How did you hear about HOPE Midwives? *
Which midwife would you prefer as your primary care provider? *
What is your due date? *
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What is the first date of your last period? *
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How did you calculate your due date? *
How many pregnancies have you had (including this one)? *
How many vaginal births have you had? *
Please tell us about your vaginal birth(s)
How many cesarean births have you had? *
Please tell us why you had the cesarean birth(s)
Tell us about your experience in your post-partum(s) - infant feeding, moods, physical recovery, etc.
Have you had midwifery care before? *
Which practice?
Have you applied for a midwife on Alberta's Provincial Application site? *
Do you have Alberta Health Care? *
Do you have any medical conditions? *
Do you take prescription medication? What and why? *
Have you ever had an abnormal PAP requiring a LEEP, cone biopsy or other procedure on your cervix? *
Where would be your ideal birth location? *
What makes your chosen birth location important to you? *
How does your partner feel about midwifery care? *
Where does your partner feel you should give birth? *
Is there anything else you'd like to add?
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