Register for care

Name (as it appears on your BC CareCard) *

First Name

Last Name

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of YOUR birth *

MM

DD

YYYY

Partner's Name (if applicable)

First Name

Last Name

Have you previously received midwifery care?

Yes

No

Are you a previous client of Salt Spring Midwives?

Yes

No

Have you previously had a Cesarean Section?

Yes

No

When was the first day of your last period? *

MM

DD

YYYY

When is your baby's estimated birth date?

MM

DD

YYYY

How was the baby's birth date determined? *

Last period date

Conception date

Early Ultrasound

Fertility support

Would you like a dating ultrasound? *

We offer this before our first visit because this is the most accurate way to date your pregnancy, and these ultrasounds can be challenging to book ahead of time on Salt Spring Island. With all ultrasounds, sometimes we are still unable to book them on Salt Spring Island. You don't need to decide now, please let us know if you'd like to discuss.

Yes

No

Unsure

Where are you thinking about birthing your baby?

Salt Spring Midwives are primary care providers for pregnancy and birth and we can support your birth at home or hospital on island. We will coordinate care for you off island if that is your choice, or if reasons arise in your pregnancy where birthing off island is recommended. Midwives are experts in healthy, low risk pregnancy and birth. We will spend lots of time discussing your health throughout your pregnancy to help you make an informed decision about where the best place is for the birth of your baby.

Home

Hospital

On Salt Spring Island

Off Island

Other location

Unsure