Intake Form for Clients

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 NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

YearMonthDay
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*
Pronouns*
Do you or your partner identify as First Nation, Metis, or Inuit?

YesNoOther
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:*

YesNo
Personal History
What is the first day of your last menstrual period?*

YearMonthDay
Date
What is your estimated due date?*

YearMonthDay
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)?*

HospitalHomeUndecidedOther
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):*

DiabetesHigh blood pressureHeart conditionsHistory of blood clotsAuto-immune conditionsNoneOther
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 diabetesHigh blood pressure or pre-eclampsiaCholestasisFetal growth restrictionShoulder dystociaPostpartum hemorrhage3rd or 4th degree tearsNoneOther
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

YesNo
Please be sure to add mail@ponderosamidwives.ca to your contacts to ensure our emails do not go to your junk mail
Should be Empty:

Interested in becoming a client with us?

Personal Information

Personal History

Final questions

Please be sure to add mail@ponderosamidwives.ca to your contacts to ensure our emails do not go to your junk mail