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DANDELION MIDWIFERY Your Peninsula Midwives 
Located in Brentwood Bay Village
Michele Buchmann, RM and Joanna Webber, RM

C1-7159 West Saanich Road, Brentwood Bay, BC V8M 1P7
Phone 778.351.4441  Fax 778.351.4442 
dandelionmidwifery@gmail.com

Intake Form 

Please fill out our intake form completely. Once we have received your completed form, we will be in touch. Thank you.

Name (as it appears on your BC ID):
DOB:
Age:
Preferred name:
If you have a partner, please tell us their name:
Age: 
Address (incl postal code):
Phone:
Cell: Home: Work:
Email address:
Family physician:
  
First day of last menstrual period:
    Normal?:     Yes     No
Estimated due date:
Are you taking folic acid?:
Yes  No Date of most recent PAP:
Height:   Weight:   Allergies:
Brief Health History:
Obstetric History:
Reasons for Midwifery Care:
Source of Referral:

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