To apply for midwifery care, please complete this form.

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In Alberta, families choose either a Midwife or a Physician for their maternity care.

To apply for midwifery care, please complete this form.The form may not work from your cell phone / tablet. Please apply from a laptop or desktop.

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Do you have Alberta Health Care? YesNo

First Name

Last Name

Email

Home Phone

Cell Phone

Street Address

City

Postal Code

Are you planning on moving during your pregnancy? NoYes

If yes, which neighbourhood will you be living in when your baby is due?

Have you had a baby before? NoYes

Have you ever had a caesarean delivery? NoYes

Due Date Day Select12345678910111213141516171819202122232425262728293031

Due Date Month SelectJanuaryFebruaryMarchAprilMayJuneSelectJulyAugustSeptemberOctoberNovemberDecember

Due Date Year Select202020212022

Midwife Team Preference No PreferenceAirdrie Bees (Christia, Bayli, Olu)Airdrie Birds (Julie, Michelle)Harmony 1 (Connie, Jeannette)Harmony 2 (Chelsea, Stephanie)Harmony 3 (Jenn, Tiffany)Moonstone Green (Nicola)Morning Star Pearl (Helen & Deb)Morning Star Rose (Elise, Taryn, Patty)Nemi Tobins (Solo)New Roots Elm (Shannon S, Melissa)New Roots Willow (Shannon K, Monique)Nurturing Families Team (Nicole)Cherry Blossom Midwives (Brooks, Taber)Midwives of Medicine HatMidwives of Grande Prairie

Have you had care from Birth Partnership Midwifery Services before? NoYes

Where would you like to have your baby? SelectHomeBirth CentreHospitalUndecided

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Do you have any medical concerns that require you to see a medical doctor on a regular basis? NoYes

Do you take any prescription medications? NoYes

If you answered yes to either, please briefly elaborate (all responses are confidential)

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