Interested in becoming a client with us?
Thank you for your interest in becoming part of the Ponderosa family. We will review your application and our administrator will get back to you within 10 Business days. Please be aware there is no e-mail confirmation after you submit this page. If you do not hear from us within 10 Business days, please feel free to e-mail or call us to confirm your submission. ______________________________________________________________________ Please note: ONLY ONE REGISTRATION FORM IS REQUIRED. INCOMPLETE FORMS WILL NOT BE PROCESSED.
Personal Information
Full Name (as it appears on your Care Card)
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
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The Bahamas
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Canada
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Chile
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Christmas Island
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Cote d'Ivoire
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Democratic Republic of the Congo
Denmark
Djibouti
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Ecuador
Egypt
El Salvador
Equatorial Guinea
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Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Ghana
Gibraltar
Greece
Greenland
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Guinea
Guinea-Bissau
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Hungary
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
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Tuvalu
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Vatican City
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Country
Birth Date
*
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Year
Please select a month
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Month
Please select a day
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Day
Public Health Number
*
BC Services Card Number
Preferred Pharmacy
*
Name and Location
Emergency Contact
*
Please include name & relationship to you
Emergency Contact Phone Number
*
Do you plan on moving during the pregnancy? If so, where?
*
Are you moving away from current city?
Gender
*
Please Select
Female
Male
Non-binary
Ask me!
Pronouns
*
Please Select
She
He
They
Other
Do you or your partner identify as First Nation, Metis, or Inuit?
Yes
No
Other
Primary Care Provider
GP/NP who provides care outside of pregnancy
Primary Care Provider Phone Number
Do you already have a maternity care provider for this pregnancy? If so, please tell us their name. *note: if you transfer care to us, this will end your care with this provider
I consent to be contacted by the midwives with my medical information throughout my care via any of the included contact information:
*
Yes
No
Personal History
What is the first day of your last menstrual period?
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-
Year
-
Month
Day
Date
What is your estimated due date?
*
-
Year
-
Month
Day
Date
Please list the number of pregnancies you have had and in what year(s):
*
Write N/A if not applicable
Where are you hoping to give birth (understanding that circumstances or preferences may change during pregnancy)?
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Hospital
Home
Undecided
Other
Please briefly tell us about your previous pregnancies & birth experiences (if applicable):
*
Write N/A if not applicable
Have you had any cesarean sections? If so, how many?
*
Write N/A if not applicable
If you have had a cesarean section before, how do you hope to give birth this time (understanding that circumstances or preferences may change during the pregnancy)?
Trial of labour after cesarean section (TOLAC)
Elective repeat cesarean section (ERCS)
Other
Please let us know if you have any of the following health conditions (click all that apply):
*
Diabetes
High blood pressure
Heart conditions
History of blood clots
Auto-immune conditions
None
Other
List any other health problems, no matter how insignificant they may be:
*
Write N/A if not applicable
Please list any medications you are taking and the indication:
*
Did you experience any complications in a prior pregnacy such as (click all that apply):
*
Gestational diabetes
High blood pressure or pre-eclampsia
Cholestasis
Fetal growth restriction
Shoulder dystocia
Postpartum hemorrhage
3rd or 4th degree tears
None
Other
Have you experienced any miscarriages, terminations, or infant loss? At what week of pregnancy, or what age? Please include any complications:
*
Write N/A if not applicable
Final questions
Are you a repeat client? If so, who was your previous midwife (team)?
Is there anything else you want us to know?
How did you hear about us?
What brings you to seek care with a Registered Midwife?
*
I am interested in postpartum care after my baby is born. I give my permission to be contacted if a spot opens up for postpartum care only
Yes
No
Please be sure to add mail@ponderosamidwives.ca to your contacts to ensure our emails do not go to your junk mail
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