Please fill out the form below to finish your application for midwifery care with St Albert Comments Midwives. This will assist us with organizing our new client list and our ongoing waiting list. The information is confidential and will be handled with great care.
To avoid confusion, please note that this is NOT the registration process for the Rinita Birth Centre (which is a privately-paid birthing facility for anyone with an Alberta midwife).
**Please read the information below before proceeding with your application.**
Important to Note:
We have our own internal application form and intake process. If you've already applied online though the Alberta Midwifery Request for Care, you must still fill out this form as well.
Filling out the application form does not mean you've been accepted into midwifery care.
When accepting patients into our care, we prioritize out-of-hospital birthing people (Rinita Birth Centre and home-birth).
In order to qualify for midwifery care, you must be experiencing a low-risk pregnancy.
Name as it appears on Alberta Personal Health CardPreferred Name (if different)E-mailPhoneAgeBirthdayAddress (include city and postal code)Alberta Health Care Number (please put PRIVATE PAY if you don't have valid Alberta Health Care)Estimated due dateNumber of pregnancies (including current pregnancy and miscarriages and losses)Number of deliveriesHave you had a previous cesarean birth?First day of your last menstrual period (if known)
Where would you prefer to birth? (If unsure, check all that apply)
Hospital
Rinita Birth Centre
Home
If you would like to birth in hospital, at which hospital would you like to birth?
Sturgeon Community Hospital
Royal Alexandra/Lois Hole Hospital
Misericordia Community Hospital
I am open to any hospital my midwife has privileges if it means I will have access to midwifery care (Please note St Albert Community Midwives do not have privileges' at Grey Nuns hospital)
Partner's Full NamePartner's date of birthPartner's phone numberWhat pronouns do you use?What pronouns does your partner use?
How much do you know about informed-consent and the midwifery model of care?
A lot - I like taking responsibility for my decisions and knowing my options.
Some - I look forward to understanding my care options.
Not much - I'm not sure what informed-consent is or the midwifery care model.
Are you planning on having a doula at your birth?
Yes
No
Maybe
Are you planning on attending a prenatal birthing or infant feeding class?
Yes
No
Maybe
Please explain any complications with your current and/or previous pregnancies, deliveries, miscarriages, and abortions, including gestational age of prior deliveries (examples: 35+3, 40, 41+6 weeks, etc.) Please provide us with as much detail as you can.Please explain any health concerns or conditions and list any medications you are currently taking.
Have you had midwifery care before?
No
Yes
If yes, please provide the midwives' names and year of care.Is there anything you would like us to know about you or your family before your first visit?
Are you Indigenous or Metis?
Yes
No
Maybe
Language(s) spoken
Acknowledgement
By submitting your application, I acknowledge that all information given is true and correct to the best of my knowledge, and that I have not knowingly omitted any related information. I understand that any inaccurate information may make me ineligible for midwifery care.