Intake form

First Name (required - as it appears on your health card)

Last Name (required - as it appears on your health card)

Preferred first name (if different)

Name of your partner/support person (first and last name)

Address (required)

What city do you live in? (required)

Major street intersection near your home (required)

Postal code (required)

Your Email

Please enter the best phone number to reach you at (required)

Is this number your:
 cell home partner's number other

Is it okay to leave messages? (required)
 Yes No

Alternate phone number

Is it okay to leave messages at this number?
 Yes No

Is this number your:
 cell home partner's number other

Your date of birth (required)
Month
Day
Year

When was the first day of your last menstrual period? Please note that we are unable to process your form without a sense of when you are due.
Month
Day
Year
 Not sure about when your last menstrual period was

How long is your cycle, counting from day 1 of one period (ie: Jan 1) to day 1 of the next (ie: Feb 2) : Jan 1 - Feb 2 = 32 days

If you know your estimated due date, enter it here. (required) - Need help calculating your due date? - (not available on mobile browsers)
Month
Day

 Unable to estimate your due date to the nearest month

Is this based on:

Where do you plan to have your baby? (required)

Do you have any children? (required)
 Yes No

If so, how many?

What week of the pregnancy were your babies born?

How many vaginal births have you had? (required)

Were forceps or vacuum used for any of your births? (required)

How many C-section births have you had? (required)

If so, what was the reason for C-section

What was the date (month and year) of your last C-section?

Month
Year

Did you have any problems with a previous pregnancy, such as high blood pressure, premature labour etc.? (required)
 Yes No
If yes, please provide more information

Did you have any problems with a previous birth? (required)
 Yes No
If yes, please provide more information

Do you have any medical problems that you see a doctor for on a regular basis? (required)
 Yes No
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.

Have you received any prenatal care for this pregnancy? (required)
 Yes No
If yes, with whom?

Have you had midwifery care previously?

Do you have access to OHIP coverage? (please note that OHIP coverage is not necessary to access midwifery care in Ontario)
 Yes No Unsure

How did you find us?

We treat the information gathered on this Intake Form with strict confidentiality. Please note: If we are unable to accommodate you, we will be sharing your name, date of birth and postal code with the Ministry of Health. This information is shared to demonstrate the need for more midwives in our community. Please notify us in writing if you do not want us to share this information.

You will receive a confirmation email to let you know that we have received your intake form. Please check your spam filters if you don't receive this form. We will call or email you in the next 3-4 business days. If you don't hear from us or think your form has not been received, please call us to follow up.

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