Midwifery Intake Form

Thank you for your interest in Pomegranate Community Midwives.

Please fill out the following form to the best of your ability. A number of the questions are mandatory because we need the information to help us in processing your form.

Midwifery Intake Form

About you – Step 1 of 4

Are you filling out this form for yourself?

Yes
No, I am doing it on behalf of someone else

Who are you and what is your relationship?

Contact permission

They are aware and give permission for us to contact them
Please contact me instead (use the box above to tell us how)

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First Name *

What name do you usually go by?

Same name as above
Another name

Name they go by

Last Name *

What are your pronouns?

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Do you have (a) partner(s)?

What is/are their FIRST name(s)?

What is/are their LAST name(s)?

What is/are their pronouns?

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Do you have BC Medical Card? *

Yes
No
Application in progress

BC Care Card Number

When did you apply? When are you expecting your coverage to be active?

What name is on your Medical Card card?

Same as above
Other, as below

Name on MSP card

Your date of birth (not your due date) *

Hint: make sure you input your year of birth and not this year – a frequent mistake that slows down your application.

Email *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Are you planning on staying at this address until your baby is born?

Yes
No
Looking to move within the same city
Probably moving outside of Vancouver/Burnaby

I live outside of the Lower Mainland, but will be coming to Vancouver to give birth:

If yes, what is the reason you need to come to Vancouver and who is your current pregnancy caregiver:

Approximate date of arrival in Vancouver:

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Primary phone

Alternate phone

Contact Permission

OK to call
OK to leave message on voicemail
OK to email

Do you have a regular medical caregiver when you are not pregnant?

Family doctor
Walk-In Clinic Only
None
Nurse Practitioner
Other

Medical caregiver name OR Walk-In Clinic name

Medical caregiver phone number

How would you describe your health PRIOR to becoming pregnant?

How is your health NOW that you are pregnant?

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This is pregnancy # *

If more than one…

I have had one or more vaginal births
I have had one cesarean birth
I have had multiple cesarean births
I have had both vaginal & cesarean births
I have had one or more miscarriages or abortions but not given birth

Are there any initial factors we need to know about your pregnancies or birth(s)?

Where did you give birth previously?

Home
BC Women’s Hospital
Burnaby Hospital
Other

Other Birthplace

Please fill for “Other” above.

Home Birth City

Please indicate in which city &/or country you gave birth if at home.

Who was your care provider for previous pregnancies?

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Was this pregnancy achieved through assisted reproduction? *

When was your last period?

Unsure of Last Period

Unsure of last period

If you have a regular cycle, how long is it?

Type

(e.g. Ovulation stimulation, IUI, IVF, ICSI, etc.)

Fertility Clinic

Do you know your date of ovulation or conception?

Ovulation/conception tracking method:

Assisted reproduction
Ovulation tracking: symptoms &/or OPK
Ovulation tracking: period app
I know when we had sex

When is your due date? *

For help calculating your due date: www.perinatalservicesbc.ca/our-services/screening-programs/prenatal-genetic-screening/pregnancy-dating-tool

Unsure of Due Date

Unsure of due date

Please make your best guess at your due date. We can adjust this later.

Select any tests you have had in this pregnancy

Serial HCG bloodwork to confirm viability
Full panel Prenatal bloodwork
Preconception Genetic Testing
Prenatal Genetic Screening
First trimester Ultrasound
Second trimester Ultrasound
None
Home Pregnancy Test ONLY

Who ordered these tests for you?

Family doctor
Nurse Practitioner
Walk-in clinic
Midwife
Obstetrician
Fertility clinic

Name of Provider or Clinic

Are any of these test results pending?

How did you hear about Pomegranate?

I’m a past client
Google search
Family doctor or nurse practitioner
I live in the neighbourhood/walk-by
Social media: Facebook, Instagram
Lu’ma Medical Centre
Referral from a friend
Social worker
Obstetrician
Referral from a doula
SMILE program
Fertility clinic
Referral from a past client
Other

If you previously had care from Bloom Midwives (Liv & Ali), then please select *I’m a past client*.

Who is your doula (or the doula who referred you)?

Who is it that referred you? Do you know which team?

Please specify how you heard about us

Do you know anyone who has had care at Pomegranate?

Who or what team?

We will endeavor to place you with the same team, if at all possible.

We offer a choice of birthplace. Do you have an initial preference?

Home
Hospital
Still deciding
Other

Which hospital?

Burnaby Hospital
BC Women’s Hospital

With few exceptions, BCWH does not accept patients who live outside of Vancouver. If you choose this hospital but are not eligible, your application will be delayed, which may result in you missing a last spot on our rosters.

Please tell us more about your choice of birthplace

I am planning to SCHEDULE a caesarean birth

My preference is vaginal birth
Absolutely planning a cesarean*
Prefer cesarean but considering options*

*With rare exception, Pomegranate Midwives do not usually provide care for those who start their pregnancy planning to birth by scheduled cesarean. If your preference is this type of birth, then we recommend that you connect with an Obstetrician who can help you have the type of birth you would like.

Please give us more information about why you are needing/choosing a cesearean:

I am searching for midwifery care ONLY for the postpartum period (i.e. after the baby is born)

NO. I am looking for care throughout the pregnancy, birth and postpartum period
YES, I only need a midwife after the baby is born.

While our main focus at Pomegranate, is providing full-scope midwifery (prenatal, birth and postpartum), we do have a team that is offering care just in the postpartum period. If this is truly what you are interested in, please select the TURQUOISE TEAM in the next question.

Who is your careprovider until your baby is born?

Please tell us more about your pregnancy and why you are needing/choosing midwifery after your birth:

All of our midwifery teams offer home birth as an option. We have two teams based in Vancouver with privileges at BC Women’s, and two teams based in Burnaby with privileges at Burnaby Hospital. Please see our MIDWIVES page to review members of each team.
*Some of our midwives are on maternity or educational leave, so they may not be available.*

See more about Huckleberry Midwives here.

Is there any particular team you would like to work with?

Choice of teams

ANYONE
RED (Vancouver)
JADE (Burnaby)
TURQUOISE (Postpartum only)

The Indigenous-led midwifery team, HUCKLEBERRY MIDWIVES, has moved to the Strathcona Midwifery Collective. If you are seeking care with them, please complete the intake form on the Strathcona website: www.strathconamidwiferycollective.com/intake-form

Are you interested in having a midwife who can provide some care in any of the following languages?

German
Hebrew
Other

Do you speak any other languages?

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Pomegranate Community Midwives is grateful to provide care on the unceded territories of the Musqueam, Squamish, and Tsleil-Waututh nations. We strive to provide culturally safe care for Indigenous clients.

Do you or your partner(s) identify as an Indigenous?

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Is there anything else about yourself or your health you would like us to know?

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Frequently Asked Questions

What can I expect during my first visit?: During your first visit with a midwife from your team, you will review your medical history and any current pregnancy information you can share, including relevant information about yourself and your family. Your midwife will review any upcoming tests and care options based on how far along you are in your pregnancy and what your choices are. Midwifery is based on informed choice – we do our best to make sure you understand any options you have so that you can make an informed decision about your care. If you have any health records you think would be helpful, please bring them along. If you have a partner and would like to bring them, they are welcome to join. First visits are often 30-45min plus time after to book subsequent appointments.
Are there resources I can read to help prepare?: Our resources section has some helpful information and we aim to keep this section as updated as possible. If you have any questions about helpful resources, please ask your midwife.
Are my information and contact details secure?: Your privacy is very important to us. This information is only used internally at Pomegranate to aid us in providing individualized care. We do not share it with anyone.
How can I keep informed with the latest news and Pomegranate events?: We have ongoing free information sessions as well as private classes and workshops at the clinic. The best way to stay informed is to follow up on our website, FaceBook and Instagram and keep your eyes out for posters at the clinic with upcoming dates.