Request Midwifery Care

Email

info@earthsidebirth.ca

Follow @earthsidebirth

First Name

Last Name

Phone

Your Date of Birth

Email

Do you know where you want to give birth?

First Day of Last Period

Due date (if known)

Address

If you are requesting a specific midwife, please enter the name here

Preferred Pronouns

Do you have any children?

Emergency Contact Name and Number

What ethnic background do you identify with?

If you identify as Indigenous, please specify (First Nations/Metis/Inuit) and if you are status or non-status. We prioritize intakes for Indigenous families, and knowledge of your status and health coverage helps us in providing care and connecting your family with additional resources when applicable.

Is there anything else you would like us to know?

Registered Midwives and Lactation Consultants

#1-481 Head St Esquimalt BC

www.earthsidebirth.ca

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