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Midwifery INTAKE FORM

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)

Is there anything else you want us to know? (eg Team Preferences)

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.

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.​

Do you have a preferred place of birth?

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 serious medical or health issues we should know about?

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