Patient Intake Form (Prenatal) Your preferred name: * Legal name, if different than preferred name: First Name Last Name If you have a BC Provincial Health Number, please enter it here: * If you do not have a BC PHN, please enter relevant information about your healthcare coverage Your date of birth * MM DD YYYY Your email address: * Your phone number: * (###) ### #### Your home address * Address 1 Address 2 City State/Province Zip/Postal Code Country What is the best way to contact you? * Phone Email Would you like to add an alternate contact? For example, your support person or your partner? If yes, please enter their information below. How many weeks pregnant are you? * It's ok if you're not sure—just provide your best estimate. If known, what is your EDD (due date)? * MM DD YYYY Have you been pregnant before? * If yes, please indicate how many times. Have your received any prenatal care for this pregnancy? * Yes, in hospital Yes, from my Primary Care Provider No Not sure Do you currently have a Primary Care Provider? * If yes, please enter their name & contact information here. If no, please enter "No PCP" Would you prefer to have your birth... At home In hospital No preference Not sure Is there anything else you would like us to know? Thank you for trusting us with your care.We look forward to seeing your at Rosehips Midwifery! Once your information has been received, someone will reach out to you with an appointment date and time.If you need to reach us sooner, please phone the clinic at 1-778-400-3073