NEW PATIENT FORM

The clinic is available residents of the North Shore (North & West Vancouver) & Sea to Sky region with active BC MSP coverage. Proof of address required. At this time we are not seeing patients with private insurance.

Your first ultrasound is an exciting milestone! The procedure is booked by your family doctor or walk in clinic: information from the ultrasound is needed for your appointments with us.

We are not able to book your first appointment until we have a copy of your dating ultrasound report. Please complete this form once you have completed your ultrasound.

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Personal Information

Surname

Given Name(s)

Phone

Personal Health Number

Date of Birth (YYYY-MM-DD)

Street Address

City

Postal Code

Family Doctor (if applicable)

About This Pregnancy

First Day of Last Menstrual Period (LMP) (YYYY-MM-DD)

Expected Due Date (YYYY-MM-DD)

Have you completed your dating ultrasound already?

When and where is / was the ultrasound appointment?

When were you last seen by a care provider for this pregnancy?

Are you on the waitlist for a midwife for Prenatal care?

If so, which midwifery group are you waitlisted with?

Additional Message

Thank You!

Personal Information

About This Pregnancy

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LIONS GATE HOSPITAL
231 E. 15th St.
3RD FLOOR
North Vancouver