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Intake Form

Please fill in all of the information below.  We will get back to you within 3 weeks of you submitting this form.  No phone calls before this time-frame please.  If you have been in care with us before, please indicate which midwives were involved in your care in the ‘how did you hear about us’ section at the bottom of the page.

Your Full Name: (required)
Your Date of Birth: (dd-mm-yyyy) (required)
Your Partner's Name:
Your Email Address: (required)
Your Phone Number: (required)
Your Address: (required)
Your City: (required)
Your Province: (required)
Your Postal Code: (required)
Have you had a baby before?  Yes No
How many times have you been pregnant:
How many times have you given birth:
How did you give birth (Check all that apply):  Vaginal Cesarean section Forceps/Vacuum
Did you use a midwife?  Yes No
If so, who? (Check all that apply):  Niagara Midwives Lincoln Midwives Other Ontario Midwives Other Midwives
First day of your last normal menstrual period: (dd-mm-yyyy)
Estimated Due Date: (dd-mm-yyyy)
Where do you plan to have your baby?
Have you had problems with a previous pregnancy or birth?  Yes No
If yes, explain:
Do you have a family doctor?  Yes No
Doctor Name:
Doctor Phone Number:
Do you have any medical concerns that require you to see a medical doctor on a regular basis?  Yes No
Do you take any prescription medications?  Yes No
If you answered yes to either, please briefly elaborate (all responses are confidential):
Please tell us what appeals to you about midwifery care and any questions you may have for the midwives?
How did you hear about us?
 
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