Client Intake Form

Items marked with a * are required

Please read the privacy statement before completing this application

If you are not comfortable submitting your information online, you have the option of phoning our 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)*

Name of your partner/husband:

Primary language that you speak at home:


1st phone number: (999-999-9999)*
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2nd phone number: (999-999-9999)
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Email Address:*


Home Address:* (Please include apartment number)

City:

Postal Code:*

Are you a resident of Ontario?:*


Your height:*

Your weight (before getting pregnant):*

Date of first day of last period:*

Baby's due date (if you know it):


Name of your family doctor:


Have you had prenatal care yet this pregnancy? *

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


Past or Present Medical Conditions: please check all that apply

Please provide details of anything you have checked off *

List any allergies:

Please list all medications you are currently taking and for what purpose*:


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

Number of times you have given birth: *

Have you delivered by cesarean section?

Have you delivered at home?

Please provide details of your previous pregnancies, including any complications:

Please list Delivery Date / Description (eg preterm, induction, forceps, any complications):


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? )


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.



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 three business days, please phone the office at 519-568-8282.