Request for Care

For Care Providers who are looking for a referral form for their office click HERE for download

For clients looking for full scope midwifery care please fill out below  

Pregnancy, Labour/Birth, Postpartum until 6w
Legal Name Address Contact Number E-mail Your Date of Birth Your PHN (found on the back of your CareCard, BCDL, or BC Services Card) Your Estimated Due Date How many times have you been pregnant, including this time?
Do you have any medical conditions such as high blood pressure, diabetes, epilepsy, or thyroid issues?
yes
no
If yes, please provide more information about their duration, severity, and what treatment (if any) you are receiving. If yes, please provide more information. About Me - is there anything you’d like to tell us about yourself? Submit

Full postpartum care only 

Day 1 of babes life until 6 weeks old
Legal Name Contact Number Address E-mail Your Date of Birth Your PHN (found on the back of your CareCard, BCDL, or BC Services Card) Your baby's birthdate About yourself: Is there anything you’d like to tell us? Are you a repeat client? Anything that feels important to you? Submit

Lactation Consultation by IBCLC Amanda Emsley

1-8 visits to support feeding your baby. Day 1 to 6w old.
Legal Name phone number E-mail Your Date of Birth Your PHN (found on the back of your CareCard, BCDL, or BC Services Card) Your baby's birthdate About Me - is there anything you’d like to tell us about yourself? Submit