Full Name *
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Date of Birth *
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Street Address
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Postal Code *
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Contact Phone Number *
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Email Address *
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Do you have OHIP? (Midwifery care is free to residents of Ontario even without OHIP)
First day of your last menstrual period (LMP)? *
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What is your estimated due date (EDD)?
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Are you a repeat client of Ottawa South Midwives?
If you would like to request a specific midwife, please indicate below (subject to availability):
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How many times have you given birth? *
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Have you ever given birth vaginally? *
Have you ever had a cesarean section? *
Where are you planning to give birth?
Do you have any of the following health conditions: type 1/type 2 diabetes, serious heart or kidney disease, history of pulmonary embolism? *
How did you hear about us?
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