New Client Form

Congratulations on your pregnancy!!

There are some changes happening at 307-223 Nelson’s Crescent! Starting March 1st, your midwifery care will still be provided by the same midwives, just under the banner of Aveta Midwifery (pronounced AV-ta). Any intake requests will be forwarded to Aveta’s website. We look forward to continuing your care and appreciate your patience during the business transition.

Please provide the following:

    1. Your full name (as seen on your care card):

    2. Your BC care card number:

    3. Your email address:

    4. Your address (PLEASE PROVIDE YOUR FULL ADDRESS, including city, apartment or suite # and postal code):

    5. The best phone number to reach you at:

      Is it ok to leave a message? YesNo

      Your partner's name and contact number:

    6. Your date of birth:

    7. Your age at your estimated due date:

    8. The first day of your last menstrual period:

    9. Your estimated due date:

    10. Any previous pregnancies? YesNo

      If yes, please provide some details (dates, pregnancy loss or delivery, type of delivery [spontaneous, vacuum, forceps, C-Section], any complications, doctor or midwifery care etc...)

    11. Any significant medical conditions or ongoing medications? YesNo

      If yes, provide a brief outline

    12. Please provide your Family Physician's name and phone number (or walk in clinic):

    13. Have you had any ultrasounds, blood work or prenatal genetic screening done for this pregnancy? YesNo

      If yes, please specify location, date and who it was ordered by.

    14. How did you hear about our office?

      FriendFamilyPhysicianWebsiteMABC/CMBCOther

      If referred by a friend, family or physician, please let us know who to Thank!

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    Please note:  we will phone you within one week to let you know if we can book a consultation visit for you 🙂