Intake Form

Name *

First Name

Last Name

Do you, your baby, or your partner identify as Indigenous?

Choose one.

Yes

No

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone/Main Phone Number *

(###)

###

####

Do you require an interpreter?

Yes

No

Can we leave messages at the phone number and/or email address you provided? *

Choose one.

Both phone and email are ok

Phone/voicemail only

Email only

Name of support person

First Name

Last Name

Support person or partner/Emergency phone number *

(###)

###

####

Are you a previous client? *

Choose one.

Yes

No

Have you had a previous cesarean section? *

Choose one.

No

Yes, and I would like to plan another C-section for this birth.

Yes, and I would like to plan a vaginal birth for this birth.

Have you had care from another care provider in this pregnancy? *

Choose one.

No

Family Doctor/Nurse Practitioner

Obstetrician

Midwife

Fertility Clinic

Have you had care to date?

Check all that apply.

Blood work

Ultrasounds

Neither

Planned place of birth

Choose one.

Undecided

Out of Hospital

Penticton Regional Hospital

I authorize Willow Midwives to access my medical records relevant to my pregnancy care (e.g. results of most recent pap smear, ultrasound results, records of previous births) *

Choose one.

Yes

No

Perinatal Services BC provides evidence based guidelines and maintains statistics to guide and improve perinatal care in British Columbia. Willow Midwives requests your consent for sharing your chart information anonymously, as mandated, with Perinatal Services for the purpose of reporting and data collection. *

Choose one.

I consent

I do not consent

Healthy From The Start is a program through Interior Health (Public Health) that connects pregnant people to a variety of resources in their community. Please indicate whether we can share your contact information with Healthy From The Start. *

Choose one.

Yes, please share my contact information.

No, please do not share my contact information.