Intake Form
for Madawaska Valley Midwives
Name (as it appears on your OHIP/Health card) *
Have you been in the care of midwives before? *
Are you a repeat client of Madawaska Valley Midwives? *
Email address *
Enter due date here:
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You can't provide a due date because…
Address *
City *
Province *
Postal Code *
Are you a resident of Ontario? *
NOTE:
Midwifery care in Ontario is free for Ontario residents, whether or not you have an OHIP card. Non-residents of Ontario can access midwifery care but must pay for this service. Please call us if you would like more information, 1-877-757-0808.
Are you a Canadian citizen? *
Month and Day of Your Birth: *
MM
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DD
Year of Your Birth *
Phone *
Is it okay to leave a message? *
Alternate phone
Is it okay to leave a message?
Clear selection
When was the first day of your most recent menstrual period (LMP)? *
MM
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DD
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YYYY
How long is your menstrual cycle? (enter number of days): *
Note:
Please note that we are unable to process your form without an LMP or a due date.
How many pregnancies have you had? *
How many times have you given birth? *
How many vaginal births have you had? *
How many c-sections have you had? *
Do you have any major medical problems like hypertension, diabetes or epilepsy? *
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving. *
Did you have any problems with a previous pregnancy or birth? *
If yes, please provide more information: *
Where do you plan to have your baby? *
Why are you seeking a midwife?
The Ministry of Health asks us for some information about people seeking midwifery care to track the demand of midwives in the province. May we give your information to the Ministry of Health? *
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