Client Application Form Items marked with a * are required We regularly review our list of applicants for midwifery care. We will contact you by email to book your first appointment or to let you know if you are on our waiting list. If you have not heard from us within FIVE business days, please phone the office at 519-568-8282. Your first name:* Your last name (on health card):* Your last name (if different from your health card): Your date of birth: (month/day/year)* JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Name of your partner/husband: Primary language that you speak at home:* 1st phone number: (999-999-9999)* -- 2nd phone number: (999-999-9999) -- Email Address:* Home Address:* (Please include apartment number) City: Postal Code:* Are you a resident of Ontario for at least 12 months?:* YesNo If No, what is your status in Ontario (ie visitor, foreign student, landed immigrant, refugee): VisitorStudentPermanent ResidentRefugee ClaimantResident of another province/territory Do you have an Ontario Health Card?:* YesNo Your height:* Your weight (before getting pregnant):* lbskg Date of first day of last period:* Baby's due date (if you know it): Do you have a family doctor? YesNo If Yes, name of your family doctor: Have you had prenatal care yet this pregnancy? * ObFamily DoctorMidwifeNo care yet Have you had any of the following done in this pregnancy? Blood workUltrasound Past or Present Medical Conditions: please check all that apply* Major health conditions requiring specialist involvement or medicationsSurgeryDiabetesHigh blood pressureHeart issuesSeizuresKidney issuesLung issuesBlood clotting issuesMental health issuesCancerN/A Please provide details of anything you have checked off * List any allergies: Please list all medications, including vitamins, you are currently taking*: Number of times you have been pregnant (including this one): * Number of times you have given birth: * Have you delivered by cesarean section? YesNoN/A Have you delivered at home? YesNoN/A Please provide details of your previous pregnancies, including any complications: Please list Delivery Date / Description (eg preterm, induction, forceps, any complications): Have you previously been a client of Genesis Midwives? YesNo Please note that Genesis Midwives follows Public Health Guidelines when it comes to Covid-19.This includes the wearing of masks for all home, clinic, hospital or any other indoor visit at all times. Are you comfortable with this policy?:* YesNo Do you agree to ‘virtual communications’ with Genesis Midwives? This includes all medical matters with midwives, student midwives and admin, over but not limited to Phone, Email, Text Message, Website, Patient Portal, and/or Videoconferencing:* YesNo Are you interested in learning more about the free “Me Breastfeed” Prenatal workshop and Breastfeeding Buddies resources?:* YesNo Is there anything else you would like us to know? (eg Do you have any specific requests or birth plans? How did you hear about us? Is there a specific midwife you know? ) Please be aware that there are steps up to the clinic. Should you have any mobility or other concerns, please let us know how we may accommodate you. As part of our statistical reporting to the Ministry of Health and Long-Term Care we are asked to provide the first name, last name, date of birth and postal code of each woman who applies for care and is not accommodated. You will not be contacted by the Ministry. Do we have your consent to release this information? * YesNo We will contact you by phone or email if we need more information.