Postpartum Intake Form | Semiahmoo Bay Midwives

Postpartum Care Intake Application

Midwifery care for birthing person's and newborns, up to 6 weeks postpartum. Please note, we are only able to accept a very limited number patients each month.

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?
If your baby is already born:
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?
- Yes
- No
- Planned but have not seen yet
Is your family doctor, or prenatal care provider aware you are seeking midwifery care?
- Yes
- No
Do you have any other current risk factors, or information you wish to share?
CAPTCHA

Postpartum Care Intake Application

If you are still pregnant:

If your baby is already born: