New Clients

Intake Form:

If you haven't heard back from us in one week please call the office at:

250-338-4810

Name on Care Card

Preferred Name

Phone Number

Permission to Leave Voicemail?

Due Date

This is Baby #

Any Significant Medical Conditions? (Diabetes, Heart Conditions, etc.)

Are you planning home birth, hospital birth or unknown? Please describe any barriers to care that we should be aware of in order to better serve you. Some examples being: limited access to transportation, phone or internet, living in remote location, previous negative interactions with healthcare system (e.g. racial discrimination). Any other questions/comments?

Thanks for submitting! If you haven't heard back from us in one week please call the office at: 250-338-4810