Postpartum Care Intake Request | Semiahmoo Bay Midwives

Name (As appears on CareCard)

First Last

Called or Preferred Name (if applicable)

Date of Birth

Care Card Number

Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

If you are still pregnant:

Who is your primary care provider for pregnancy?

Where is your intended place of birth?

Estimated Due Date

Planned Caesarean Date, if applicable

Are there any maternal or newborn risk factors or concerns?

Baby's Name

Baby's Care Card Number

Date of Birth (Baby)

When was your Due Date?

Where was baby born?

Were there any birth complications or concerns since birth?

Have you seen your family doctor or other care providers since delivery?

Is your family doctor, or prenatal care provider aware you are seeking midwifery care?

Do you have any other current risk factors, or information you wish to share?

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