Blume Maternity Care

SIGN UP FOR POSTPARTUM CARE

If you are interested in postpartum care for you and your newborn, please complete the registration form below. Our team will be in touch with you as soon as possible.

First Name

Last Name

Email

Phone Number

Date of Birth

Year

Month

Day

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

Multi-line address

Country/Region

Address

City

Zip / Postal code

When Is Your Due Date?

Year

Month

Day

Did You Already Deliver Your Baby?

Yes

No, I Am Still Pregnant

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.

Is There Anything You Would Like Us to Know About You or Your Family?

Important Note — Please do NOT include any personal medical or health information on this form. Our team will reach out soon to collect that information securely from you.

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

Who Is Taking Care of You During Pregancy?

Surrey Prenatal Clinic or Surrey Maternity Centre

Another Midwifery Clinic in Surrey

Another Midwifery Clinic in Surrey (Not in Surrey)

My Family Doctor

By checking this acknowledgment box, I understand that this does not mean I am automatically signed up for postpartum 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.

SIGN UP FOR POSTPARTUM CARE