Please fill out this form if you want care from the midwives. You don’t have to fill out any part that you are not comfortable with. If you don’t hear back from us within 1 week, please call us at 250-900-3909. Preferred Name First Name Last Name Name on Care Card (health Card) * Preferred Pronoun(s) She/Her They He/Him Other Email Phone (###) ### #### Partner's Name (if Applicable) First Name Last Name Partner's Preferred Pronoun(s) * She/Her He/Him They Other Street Address Apt # - House/Building # and name of street) PO Box Town First day of Last Period/Moon (if you know) MM DD YYYY Your baby's estimated due date (if you already know) MM DD YYYY Have you had a dating ultrasound? Best ways to contact you Phone Text Email Can we leave a message? Anything else you would like us to know? Thank you!