First Name (required - as it appears on your health card)

Last Name (required - as it appears on your health card)

Preferred first name (if different)

What's your preferred gender pronoun? (e.g. her, him, they)

Name of your partner/support person (first, last name)

What's your partner's preferred gender pronoun? (e.g. her, him, they)

Your Email

City where you live: (required)

Major street intersection near your home (required)

Postal code (required)

Language(s) spoken at home

Please enter the best phone number to reach you at (required)

Is it okay to leave messages? (required)
YesNo

Please enter your work phone number (leave blank if you do not want us to call this number)

Is it okay to leave messages?
YesNo

Alternate phone number

Is it okay to leave messages at this number?
YesNo

Is this number your:
cellhomepartner's numberother

Your date of birth (required)
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031
Year ---20062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960

When was the first day of your last menstrual period? Please note that we are unable to process your form without a sense of when you are due.
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031
Year ---20182017201620152014

Not sure about when your last menstrual period was

If you know your estimated due date, enter it here. (required) - Need help calculating your due date? - (not available on mobile browsers)
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031

Unable to estimate your due date to the nearest month

Is this based on:
---last menstrual periodultrasoundconception dateother

Where do you plan to have your baby? (required)
---homehospitalbirth centreundecided

Do you have plans for pain medication during your birth?
---Yes, I'm planning for an epidural.No, I'm planning for a natural childbirth.Uncertain, I need more information.

How many vaginal births have you had? (required)
---012345678+

How many C-section births have you had? (required)
---012345

Do you have any medical conditions like diabetes, epilepsy or thyroid issues? (required)
YesNo
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.

Does anyone in your immediate family have diabetes or thyroid conditions? Your immediate family is your biological parents, grandparents or siblings.
YesNo

Did you have any problems with a previous pregnancy or birth? (required)
YesNo
If yes, please provide more information

Have you received any prenatal care for this pregnancy? (required)
YesNo
Please tell us the healthcare provider's name. If no, please say 'no.'

Phone:

Fax:

Why are you seeking a midwife?

Have you been cared for by a midwife in the past? NoYes, at The Midwives' ClinicYes, at another clinic in OntarioYes, at a clinic outside of Ontario

If yes, what year: (if more than once, give the most recent year)

If you've had a midwife from our clinic, please tell us the name:
---Christine AllenDeborah BonserMehran BordbarKristen CampbellStella CapiscioltoSarah DaviesVanessa DixonJennifer GardinerTracy GersterNabal KanaanSarah LeslieMelinda LevyChristie LockhartSimone RosenbergEsther WillmsSarilyn Zimmermanother midwife/can't remember

Do you prefer a specific midwife from our clinic? (leave blank if not). We can't guarantee that you will be assigned to this midwife due to holidays and availability.
Preference 1:
---Mehran BordbarKristen CampbellStella CapiscioltoSarah DaviesVanessa DixonSarah FallisJennifer GardinerTracy GersterNabal KanaanSarah LeslieMelinda LevyChristie LockhartKatie O’BrienSimone RosenbergKirsten TaylorEsther WillmsSarah WilsonSarilyn Zimmerman

Preference 2:
---Mehran BordbarKristen CampbellStella CapiscioltoSarah DaviesVanessa DixonSarah FallisJennifer GardinerTracy GersterNabal KanaanSarah LeslieMelinda LevyChristie LockhartKatie O’BrienSimone RosenbergKirsten TaylorEsther WillmsSarah WilsonSarilyn Zimmerman

How did you find us?
---family doctorobstetricianinternetposter/flyerhospitalother

We treat the information gathered on this Intake Form with strict confidentiality. Please note: If we are unable to accommodate you, we will be sharing your name, date of birth and postal code with the Ministry of Health. This information is shared to demonstrate the need for more midwives in our community. Please notify us in writing if you do not want us to share this information.

You will receive a confirmation email to let you know that we have received your intake form. We will call you in the next 2-3 business days. If you don't hear from us or think your form has not been received, please follow up at 416-424-1976.