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Full Name
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Your answer
Date of Birth
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MM
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DD
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YYYY
Street Address
Your answer
Postal Code
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Your answer
Contact Phone Number
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Your answer
Email Address
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Your answer
Do you have OHIP? (Midwifery care is free to residents of Ontario even without OHIP)
Yes
No
Not sure
First day of your last menstrual period (LMP)?
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MM
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DD
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YYYY
What is your estimated due date (EDD)?
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DD
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YYYY
Are you a repeat client of Ottawa South Midwives?
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No
If you would like to request a specific midwife, please indicate below (subject to availability):
Your answer
How many times have you given birth?
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Your answer
Have you ever given birth vaginally?
*
Yes
No
Have you ever had a cesarean section?
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Yes
No
Where are you planning to give birth?
The Ottawa Hospital - Civic Campus
The Ottawa Birth and Wellness Centre
At home
Not sure
Do you have any of the following health conditions: type 1/type 2 diabetes, serious heart or kidney disease, history of pulmonary embolism?
*
Yes
No
Not sure
How did you hear about us?
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I am a previous client
Family or friend
Internet search
Facebook / Twitter
Physician / nurse practitioner
Naturopath / massage therapist / chiropractor / physiotherapist
The Baby Show
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