Intake Form
for Madawaska Valley Midwives
Name (as it appears on your OHIP/Health card) *
Your answer
Have you been in the care of midwives before? *
Are you a repeat client of Madawaska Valley Midwives? *
Email address *
Your answer
Enter due date here:
MM
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DD
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YYYY
You can't provide a due date becauseā€¦
Address *
Your answer
City *
Your answer
Province *
Your answer
Postal Code *
Your answer
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? *
Date of Birth *
Change the YEAR to your year of birth please!
MM
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DD
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YYYY
Phone *
Your answer
Is it okay to leave a message? *
Alternate phone
Your answer
Is it okay to leave a message?
When was the first day of your most recent menstrual period (LMP)? *
MM
/
DD
/
YYYY
How long is your menstrual cycle? (enter number of days): *
Your answer
Note:
Please note that we are unable to process your form without an LMP or a due date.
How many pregnancies have you had? *
Your answer
How many times have you given birth? *
Your answer
How many vaginal births have you had? *
Your answer
How many c-sections have you had? *
Your answer
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. *
Your answer
Did you have any problems with a previous pregnancy or birth? *
If yes, please provide more information: *
Your answer
Where do you plan to have your baby? *
Why are you seeking a midwife?
Your answer
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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