Midwifery INTAKE FORM

It is with great sadness that we announce that Bloom Community Midwives will be closing its doors as of June 30th, 2023.

Charlotte Grant RM (St Paul’s Hospital/home deliveries) will continue accepting full scope (prenatal/intrapartum/postpartum) intakes via Strathcona Midwives as she will move her practice (including all existing clients) to Strathcona Midwifery Collective as of July 1st, 2023. Please visit the Strathcona Midwifery Collective webpage to register for care with Charlotte Grant and her teammate Olivia Sims.

We will also try to accommodate requests for postpartum-only clients leading up to June 2023, so please apply through our intake form.

Your midwives have been honoured to care for you and your families over the years. We wish you all the best with your pregnancy journey and are beyond sad that we won’t be the ones meeting your babies!

Bloom Midwifery Form

Please complete ALL sections as thoroughly as possible before submitting the form - this will improve our ability to triage your request in a timely manner.

*Please Note: email is solely for the purpose of communicating with you regarding your care, informing you of appointments and of up and coming prenatal classes and postpartum events.

*Please Note: phone calls from your Midwives will often come through as "Blocked Number"

Further Information for your Midwifery Team

Is there a partner or support person involved in your pregnancy? (if yes, name/relationship/phone number)

Have you received any prenatal care in this pregnancy?

(If yes, where/with whom/how many visits)

Regarding your Pregnancy, Birth, and Medical History

Is this your first pregnancy? If not, how many pregnancies and/or births have you had? Please provide details on previous births, if applicable.

Did you experience any health complications in your previous pregnancies or births?

If you have a Family Doctor, please list their name, clinic, and phone number.

Thank you for submitting your intake request! We will be in touch within 1-5 business days.

Where do you plan to give birth? Please note that we are now accepting postpartum clients only.

If you wish to have prenatal/birth/postpartum care from Charlotte Grant/Team Lotus, please visit Strathcona Midwifery Collective's webpage.

Regarding your Current Pregnancy

When was the first day of your last normal menstrual period (day/month/year)?

What is your Estimated Due Date (day/month/year)

Have you had any tests yet in this pregnancy e.g. ultrasounds or blood work.

(If yes, which ones?)

Do you have any preferences for which Team or Midwife (postpartum care only)?

Do you have any serious medical or health issues we should know about?

By submitting an intake request via our website, the sender authorizes Bloom Community Midwives to collect the individual's personal information. This information will strictly be used to create client charts and book appointments, as applicable. If the sender is submitting personal information on behalf of a 3rd party, the sender confirms they have full authorization from the 3rd party to submit such information to Bloom Community Midwives. The sender does not hold Bloom Community Midwives responsible in the highly unlikely event of a data breach.