How To Register / Community Birth Program

Date of birth

Day of birth DD

/

Month of birth MM

/

Year of birth YYYY

Do you have a card card number?

Yes No

What is the number on your care card?

Are you waiting for your care card number or are you in the process of applying?

Email Address

Street Address

How often are your menstrual cycles? Are they regular?

Have you given birth before?

Yes No

How many PREGNANCIES have you had (including your current pregnancy)?

1 2 3 4+

Have you had any prenatal visits, labs or tests in this pregnancy yet?

Yes No

Which prenatal visit, lab, or test?

Pregnancy test Bloodwork Pap test Ultrasound Other Tests

Please specify

Are you currently receiving maternity care?

GP OB Midwife Not currently receiving care

What is their name?

Do you have a family doctor?

Yes No

What is their name?

What is your primary language?

Do you also speak English?

Yes No

What is your ethnic background?

What is your occupation?

Do you have a partner?

Yes No

Do you have any children?

Yes No

What are their names and ages?

Are you interested in group prenatal care?

Yes No

How did you hear about us? (optional)

Please specify

Is there anything else you would like us to know? (optional)