Bloom Midwifery Form

*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 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! We will be in touch in 1-3 business days.