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If you are interested in receiving prenatal care, please complete the registration form below.

Due to the high volume of inquiries we receive each day, it may take 2–3 weeks for our team to respond. We truly appreciate your patience and will get in touch as soon as we are able.

PATIENT INFORMATION
Date of Birth
Year
Month
Day
Multi-line address
OBSTETRICAL INFORMATION
How Many Times Have You Ever Been Pregnant In Your Life Including This Current Pregnancy?
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
What Is Your Estimated Due Date?
Year
Month
Day
Have You Booked Your 1st Ultrasound (i.e., Dating Ultrasound)?
Yes
No
Where Do or Did You Have Your 1st Ultrasound (i.e., Dating Ultrasound)?
Valley Medical Imaging — Langley
Valley Medical Imaging — Abbotsford
West Coast Imaging — Surrey
Med Ray Imaging — Coquitlam
Other
Have You Received Any Pregnancy Care So Far (i.e., Bloodwork, Ultrasound)?
Yes
No
PRIMARY CARE PROVIDER & PHARMACY

Note — Please provide the name and location of your preferred pharmacy. If we need to prescribe medication during your pregnancy or postpartum care, we will send your prescription to this pharmacy.

MEDICAL CONDITIONS
Do You Have Any of the Following Medical Conditions? If Yes, Please Select All That Apply. If You Do Not Have Any of These Conditions, Leave This Section Blank.

Important Note — If you selected any of the above medical conditions, your pregnancy may be considered high risk and, unfortunately, you are NOT eligible for midwifery care through our practice. In this case, we recommend that your healthcare provider refer you to an obstetrician for ongoing prenatal care.

TRANSLATOR SERVICES
Do You Require A Translator At Your Appointments?
Yes. I Do Not Speak English.
No.
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.

ARE YOU A PAST PATIENT?
SURREY MEMORIAL HOSPITAL:
Our Midwives Only Deliver At Surrey Memorial Hospital. Is This Ok?
Yes — I plan to give birth Surrey Memorial Hospital.
No — I do NOT wish to give birth at Surrey Memorial Hospital. (Please note: Our midwives provide labour and birth care only at Surrey Memorial Hospital. If you choose to deliver at another hospital, unfortunately we will not be able to accept you into our practice. We recommend seeking maternity care with a provider who has privileges at your preferred hospital.)
ACKNOWLEDGEMENTS — READ CAREFULLY!

BLUME MATERNITY CARE

Unit #201 — 15149 56 Ave Surrey, BC, V3S 9A5

Phone: (236) 450-1372

Fax: (236) 260-1053

hello@blumematernitycare.ca

Blume Maternity Care would like to acknowledge that we provide services within the ancestral, traditional, and unceded territory of the Stz'uminus, Kwantlen, W̱SÁNEĆ, S’ólh Téméxw (Stó:lō), Kwikwetlem, sc̓əwaθenaɁɬ təməxʷ (Tsawwassen), and Katzie First Nations. We are committed to offering care rooted in respect, humility, and cultural safety.

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