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Register for Prenatal Education Series
Use the print button located in the top right-hand corner of the page to print this form.
Please send completed registration form and payment of $169.50 to:

A Baby's Coming Prenatal Education
Southlake Regional Health Centre
596 Davis Drive
Newmarket, ON  L3Y 2P9

Or, fax the completed form to 905-830-5804.


Registration Form

☐ Childbirth Education Classes for first-time parents $169.50.


Due Date: __________________________________________________________________________


Name: _____________________________________________________________________________


Partner/Labour Support Person: _________________________________________________________


Address: ___________________________________________________________________________


City: _______________________________________________________________________________


Postal Code: ________________________________________________________________________


Telephone Home:  ____________________________  Office: _________________________________
                                           

Email/fax: __________________________________________________________________________


Health Card Number: __________________________________________________________________


Date of Birth: ________________________________________________________________________


Family Doctor: _______________________________________________________________________


Delivering Doctor/Midwife: ______________________________________________________________


Class Time
I would prefer ☐ evening classes   ☐ weekend classes

Method of Payment

☐ Visa ☐ American Express ☐ Mastercard ☐ Cheque
 
Make cheque payable to Southlake Regional Health Centre.

Name on credit card: __________________________________________________________________


Credit Card # Expiry Date: ______________________________________________________________

Southlake Regional Health Centre
596 Davis Drive, Newmarket, Ontario   L3Y 2P9
Tel: 905-895-4521   |   TTY: 905-952-3062
Copyright © 2012 Southlake Regional Health Centre
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