Nanaimo Midwifery

First and Last Name on your Care Card(required)

Email (required)

Phone (required)

Street Address, City, Postal Code (required)

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

What are your pronouns

She / Her
They / Them
He / Him
Other

First Day of your last menstrual Period (Required)

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

Any Health Concerns?

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Yes

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If you are wanting or considering a homebirth please indicate it here.

Yes, I would like or am thinking of having a homebirth if pregnancy is healthy and it is an option.
No, I defintely want to deliver in the hospital.

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