Midwifery Intake – Shifra Centre for Wellness

Do you have Alberta Health Care?*

Name*

First Last

Email*

Home Phone

Cell Phone*

Address*

Street Address Address Line 2 City Postal Code

Are you planning on moving during your pregnancy?*

If yes, where are you moving to?

Have you had a baby before?*

Have you ever had a caesarean delivery?*

Due Date*

Midwife Team Preference*

Have you had care from Cochrane Community Midwives before?*

Where would you like to have your baby?*

Do you have any medical concerns that require you to see a medical doctor on a regular basis?*

Do you take any prescription medications?*

If you answered yes to either, please briefly elaborate (all responses are confidential)

Please provide us with a brief comment about why you are interested in midwifery care*