Community Midwives of Brantford Intake Form
If you would like to request care from our midwives, please fill out this form in its entirety. Fields indicated by a red star are required. Your request will be sent directly to us and our support staff will contact you if we are able to provide you with care.

If you would prefer to provide your details by phone or are experiencing difficulty with this form please feel free to contact us at: 519-751-6444.
What is your name?
Maiden Name?
Do you have a health card (OHIP)? *
Your birthday. *
MM
/
DD
/
YYYY
Your phone number. *
Is it okay to leave messages at this number?
Clear selection
Your email.
Your street address. *
Your town / city. *
Your postal code. *
What is your partner's name?
Have you ever had a midwife before?
Clear selection
If you have, do you remember who?
What is your estimated due date?
MM
/
DD
/
YYYY
When was the first day of your most recent menstrual period (LMP)? Please note that we are unable to process your form without an LMP or due date.
MM
/
DD
/
YYYY
How long is your cycle? *
How many times have you been pregnant (including this pregnancy?) *
How many vaginal births have you had? *
How many C-section births have you had? *
If you've had a cesarean, do you remember why? Please explain.
If you've had a C-section previously, what is your hope/plan for this birth?
Clear selection
If this is not your first baby, when was your last baby born?
MM
/
DD
/
YYYY
Have you given birth before 37 weeks? *
Did you have any complications with a previous pregnancy or birth?
If yes, please provide more information about the complication.
Do you have a preexisting health condition?
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.
Are you currently taking any medications (including vitamins)?
Clear selection
If yes, what medications?
Do you want a home or hospital birth?
Clear selection
Who is your family doctor? Please include their address and phone number.
How did you hear about Community Midwives of Brantford?
Why are you seeking midwifery care?
Anything else you'd like to tell us?
The Ministry of Health and Long Term Care asks us for some information about people seeking midwifery care to track the demand for midwives in the province. May we give your information to the Ministry of Health for this purpose? Your information is kept confidential
Clear selection
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy