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 review our Email Consent Policy
    Do you wish to communicate with our clinic via email (required)

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

    Is this number your:
    cellhomepartner's numberother

    Is it okay to leave messages? (required)
    YesNo

    Alternate phone number

    Is it okay to leave messages at this number?
    YesNo

    Is this number your:
    cellhomepartner's numberother

    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)
    YesNo

    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)
    YesNo
    If yes, please provide more information

    Did you have any problems with a previous birth? (required)
    YesNo
    If yes, please provide more information

    Are you currently taking any medication (including non-prescription items such as vitamins)? (required)
    YesNo
    If yes, please provide more information about the medication that you are taking.

    Do you have any medical problems that you see a doctor for on a regular basis? (required)
    YesNo
    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)
    YesNo
    If yes, with whom?

    Have you had midwifery care previously?

    Do you have an Ontario Health Card? (please note that Ontario Health Insurance Plan coverage is not necessary to access midwifery care in Ontario)
    YesNoUnsure

    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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