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Squamish Birth Program
Thank you for your interest in the Squamish Birth Program

We are a collaborative team of Family Physicians, Midwives, and Nurse Practitioners providing full scope maternity care on the unceded lands of the Squamish and Lil’wat Nation.  

Request for Care - Intake Form

PRIVACY: We use your personal information to provide clinical care. We do not share your data without your consent, unless required by law. 
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Last Name *
First Name *
Date of Birth *
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Pronouns
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Do you identify as Indigenous?
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Do you have a BC Care Card?  *
What is your health card NUMBER (specify province, if not BC)?  *
Phone Number *
Email Address *
Where do you live?  *
Do you have a primary care provider (Family Physician or Nurse Practitioner)? 
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If you answered yes to the above question, please list the name of your provider. 
Last Menstrual Period
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Have you previously been pregnant or given birth? 
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Please describe your previous birth(s): 
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Please tell us more about your health, including any complications that arose during pregnancy, birth, or throughout your postpartum period. 
Allergies
Medications, vitamins, supplements
If you have a team preference for office prenatal appointments, please indicate it below. 
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Squamish Birth Program offers a choice of birth location. Please indicate your initial thoughts. 
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Additional Comments: 
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