Registration

Please complete the following form to the best of your ability and click Submit.
Completing all of the fields will reduce processing time for your registration and
help you avoid being placed on the waiting list.

Contact Information

First Name:			Last Name:
Address:
City:			Postal Code:
Home Phone:			Work Phone:
Cell Phone:
Email Address:

Medical Information

Height: Weight (before pregnancy):
Name of Family Physician:
Have you ever had a midwife before?: Yes No
Have you signed up at another midwifery?: Yes No
How many times have you been pregnant (including this pregnancy)?:
How many children do you have?:
How many home births have you had?:
How many Caesarian sections have you had?:
When was the first day of your last menstrual period?:
How often do you get your periods?:	Are your cycles regular?: Yes No
Where are you planning to give birth?:
How did you hear about KW Midwifery Associates?:
Are you currently on any prescription medications?:
Additional information:
Note: The Ministry of Health is collecting data on the demand for midwives. May we have your consent to share your health card number when we receive it? This information will help get more midwives in the area. Yes No
Yes, send me email updates about KWMA events and information.