Registration at the Birth Center

* = Mandatory Field

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First name *

Email *

Health Card Number *

Fullname of your father *

Place of birth *

Address *

Last Name *

Your Date of Birth *//

Expiration date *

Mother's maiden name *

Name of your partner *

City *

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Province *

Home phone number *

Preferred language *

Territory *

Work phone number *

Postal Code *

Other phone number

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First day of last menstrual periods *

Number of previous pregnancies *

Number of previous miscarriages and abortions *

Expected date of delivery determined by ultrasound (if applicable) *

Number of previous births *

Previous C-sections *

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How many times have you received midwifery care in the past? *

Preferred location for appointments *

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Preferred midwife 1 *

Preferred midwife 2 *

Preferred midwife 3 *

Any additional information

Would you like to attend an information session (English based on demand only) *

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How did you hear about La Maison des naissances and its services? *

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