Nanaimo Registered Midwives

First and Last Name on your Care Card(required)

What are your pronouns

She / Her
They / Them
He / Him
Other

Email (required)

Phone (required)

Street Address, City, Postal Code (required)

Emergency Contact Name, Phone Number and Relationship to You. (Required)

First Day of your last menstrual Period? (Required)

Have you previously had midwifery care?

Yes, with Nanaimo Registered Midwives
Yes, with another Midwifery Clinic
No, I was with a GP/OB
No, first time pregnant

If you have given birth before please let us know a little bit about those births. Vaginal deliveries? Cesarean birth?

Any Health Concerns?

No
Yes

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