Name as it appears on your BC medical services card *
Personal Health Number (BC Care Card) *
Date of Birth DD/MM/YY *
Address including postal code *
What pregnancy number is this for you?
How many babies have you given birth to?
Have you ever had a c-section?
If yes, would you like a VBAC or repeat CS?
Where would you like to give birth? Abbotsford hospital / Chilliwack hospital / Home
First day of your last menstrual period DD/MM/YY
How long on average are your cycles? (from the first day of one period to the next)
How tall are you?
What is your pre-pregnancy weight ? (pounds)
Would you like a dating ultrasound? (between 8-12weeks)
If you've already had an ultrasound what is your due date?
Name of your family doctor
How did you hear about us? (Go ahead name drop)
Let us know about any relevant medical or pregnancy information