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Intake Form

Please fill in all of the information below.  We will email you a response within 1 week to let you know we’ve received your form (please check your junk mail).  No phone calls or emails 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? YesNo
How many times have you been pregnant:
How many times have you given birth:
How did you give birth (Check all that apply): VaginalCesarean sectionForceps/Vacuum
Did you use a midwife? YesNo
If so, who? (Check all that apply): Niagara MidwivesLincoln MidwivesOther Ontario MidwivesOther 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? YesNo
If yes, explain:
Do you have a family doctor? YesNo
Doctor Name:
Doctor Phone Number:
Do you have any medical concerns that require you to see a medical doctor on a regular basis? YesNo
Do you take any prescription medications? YesNo
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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