Birth CentreBnB Form

Birth & Breakfast Registration Form

9505-163 Street, Edmonton Alberta, T5P 3M6
Phone: 780-756-7226, Fax: 780-756-7227
email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

To register at the birth centre, fill in the BnB form below. You can submit the form online or fax it to the Birth Centre and we will contact you to confirm your booking. After you have received confirmation from us, there is a $50 administration fee that must be dropped off or mailed to Lucina Birth Centre. The remaining $370 (includes $20 GST) must be paid, in full, by the 37th week of your pregnancy. If an obstetrical and/or medical complication arises that requires you to deliver at the hospital, $367.50 will be refunded.

If you have provided a name for your midwife we will respond within a week of receipt of form with further details. If you have not provided a name for your midwife we'll assume you are still looking one and will await her name from you before responding. 

Full Name (*)

Please fill in your name
Midwife (*)

Please indicate the midwife you are registered with
Address (*)

Please fill in your address
Phone Number (*)

Please enter you phone number
Phone Number (alternate)

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Email Address

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Due Date (*)

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Food Allergies / Diet restrictions

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Anything else we should know when you stay with us for the birth?

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