Intake Form

Personal Information

First Name *

Last Name (on health card) *

Last Name (if different from health card)

Date of Birth *

Name of Partner

Primary Language Spoken at Home *

Contact Information

Primary Phone Number *

Secondary Phone Number

Email Address *

Home Address * (Please include apartment number)

City *

Postal Code *

Residency & Health Coverage

Are you a resident of Ontario of at least 12 months? *

Yes No

Do you have an Ontario health card? *

Yes No

Pregnancy Information

Date of First Day of Last Period *

Baby's Due Date (if known)

Do you have a Family Doctor? *

Yes No

Have you had prenatal care yet this pregnancy? *

Obstetrician Family Doctor Midwife No care yet

Have you had any of the following done in this pregnancy?

Blood work Ultrasound

Pregnancy History

Number of times you have been pregnant (including this one) *

Number of times you have given birth *

Have you delivered by cesarean section?

Yes No N/A

Have you delivered at home?

Yes No N/A

Please provide details of your previous pregnancies, including any complications

Please list Delivery Date / Description (e.g., preterm, induction, forceps, any complications)

After Submitting Your Form

📧 We will contact you by phone or email if we need more information.

📞 If you have not heard from us within FIVE business days, please phone the office at 519-568-8282.

Apply for Midwifery Care

Personal Information

Contact Information

Residency & Health Coverage

Physical Information

Pregnancy Information

Medical History

Pregnancy History

Additional Information

After Submitting Your Form

Form Submitted Successfully!

Submission Failed