Blume Maternity Care

SIGN UP FOR PREGNANCY CARE

If you are interested in receiving prenatal care, please complete the registration form below. Our clinic is currently full, so you will be placed on our waitlist. If we are unable to accept you for care at this time, you will automatically remain on the waitlist and we will contact you if an opening becomes available in your due month.

First Name

Last Name

Email Address

Phone

Date of Birth

Year

Month

Day

Personal Health Number (i.e., Care Card)

Multi-line address

Country/Region

Address

City

Zip / Postal code

How Many Times Have You Been Pregnant (Including Any Abortions or Miscarriages)?

How Many Babies Have You Given Birth To?

Have You Ever Had A C-Section?

Yes

No

What Is The First Day of Your Last Menstrual Period?

Year

Month

Day

How Long Are Your Period Cycles (i.e., From the 1st day of one period to the 1st day of the next period)?

What Is Your Estimated Due Date?

Year

Month

Day

Have You Booked Your 1st Ultrasound (i.e., Dating Ultrasound)?

Yes

No

Have You Received Any Pregnancy Care So Far (i.e., Bloodwork, Ultrasound)?

Yes

No

What Is The Name of Your Primary Care Provider (i.e., Family Doctor or Nurse Practitioner)?

Which Pharmacy Would You Like Us To Use For Any Future Prescriptions (If Needed)?

Is There Anything You Would Like Us to Know About You and/or Your Pregnancy?

Do You Speak a Language Other Than English?

Important Note — Whenever possible, we will do our best to connect you with a midwife who speaks your preferred language. If that is not available, then we’re happy to use translation services to support communication during your visits.

How Did You Hear About Us (i.e., Previous Patient, Social Media Advertisement, Instagram, Facebook, Your Family Doctor, Surrey Prenatal Clinic/Surrey Maternity Centre, Axis Primary Care Clinic, Amari Medical Clinic, Google Search, Friend)?

By checking this acknowledgment box, I understand that this does not mean I am automatically signed up for care with Blume Maternity Care, and that I consent to be placed on the clinic’s waitlist and understand that a team member will contact me to confirm availability.

By checking this acknowledgment box, I consent to Blume Maternity Care reviewing my health information for care assessment. I understand that my information will be kept confidential and only shared with third parties with my written consent or when required by law. I also acknowledge that submitting personal information online carries inherent privacy risks and may not be completely secure.

By checking this acknowledgment box, I understand that Blume Maternity Care only does deliveries based out of Surrey Memorial Hospital — unfortunately, our team is not able to provide home birth at this time.

SIGN UP FOR PREGNANCY CARE