MidwivesMidwifery Form

Midwifery Registration Form

Please fill out the following to apply for Midwifery care with Lucina Midwives.

This will assist us with organizing our new client list and our ongoing waiting list.  The information is confidential and will be handled with great care.

If preferred, this information can be printed and faxed to Lucina Midwives at 780-756-7227

Thank you!

Full Name (*)

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Alberta Health Care Number (*)

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Date of Birth (*)

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Street Address (*)

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City (*)

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Postal Code (*)

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Phone Number (*)

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E-mail Address (*)

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Height (ft/in) (*)

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Pre Pregnancy Weight (lbs) (*)

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First day of last period (*)

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Due Date (*)

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Number of pregnancies (*)

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Number of children (*)

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Any complications during your pregnancies or deliveries?

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Where would you like to deliver your baby? (*)

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Have you had midwifery care before? (*)

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If so, provide midwife's name

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Current Care Provider (*)

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Reason for choosing midwifery care? (*)

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Have you read the FAQs about the birth centre on the website? (*)

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