Intake Form
Thank you for your interest in receiving midwifery care with us.

Please complete the form below as accurately and completely as you can.

We will contact you by phone or email if we are able to take you into care. If we can't immediately take you into care, you will be placed on a waitlist based on your due date. We review forms and due dates every few weeks so you may not get a call immediately but that does not mean you won’t!

Please note that all of the information collected is private and confidential.
Email address *
Full Name: *
First and last name
Street Address: *
City: *
Postal Code: *
Date of Birth *
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Health card number if you have one:
Primary telephone number: *
Primary Language spoken:
Name of your partner:
Please indicate your preferred site. Note the Kilworth location provides the options of LHSC or home and the St Thomas location provides the options of STEGH or home. There are exceptions to this, however, so please call if you have a special circumstance as we wish to offer options to our clients when possible. *
Where are you interested in delivering your baby?
Clear selection
Did you take a home pregnancy test?
Have you seen a physician or other health care provider for any prenatal care this pregnancy?
Have you had an ultrasound during this pregnancy?
If yes, do you have a due date based on an ultrasound?
Please tell us when you are due.
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First day of your last period. *
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How long are your menstrual cycles? *
For example, 28 days
Are your menstrual cycles regular? *
Every month
How many pregnancies have you had? *
Including this pregnancy, any abortions, miscarriages or terminations.
How many of your babies were born at term? *
After 37 weeks gestational age
How many of your babies were born premature? *
Before 37 weeks gestational age but after 20 weeks.
Have you ever had any abortions, miscarriages or terminations? *
How many children do you have? *
Have you ever had a Cesarean Section? *
Required
Have you ever had any complications during any of your pregnancies, your baby or postpartum?
Such as gestational diabetes, high blood pressure or postpartum hemorrhage
If yes, what were the complications?
Do you have any medical conditions or health issues? If yes, please explain
Do you take any medications, vitamins or natural supplements? If yes, please list.
Do you have any allergies- medication, environmental or food? What is your reaction?
Do you have a family doctor?
If yes, please provide his/her name and telephone number and fax number
Height *
Weight *
Any additional information we should know?
Are you a repeat client? *
If yes, what were your midwives names?
Have you ever had a midwife elsewhere before?
Clear selection
If yes, where?
A copy of your responses will be emailed to the address you provided.
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