Apply for Midwifery Care
  
Please be advised that it can take up to two weeks from the time you submit
this form for us to respond. We will use the information below to determine
the availability and suitability of midwifery care for your pregnancy.

You will be notified if we can take you into our care or if you have been
placed on our waiting list as we are unable to accomodate you at this time.
Thank you.
  
Contact Information
  
First Name:*

Last Name:*

Address:*

City:*

Postal Code:*

E-Mail Address:

Primary Phone:*

Please provide an alternate phone number
in case of difficulty contacting you by your
primary contact number.
Alternate Phone:

  
Medical Information
  
Date of Birth (MM/DD/YYYY):*

 
Health Card Number:*

Health Card Version Code:

 
First day of your last period:

 
Do you normally have a 28 day cycle?*
Yes No 

If no, how many days is your cycle?

 
Is this your first pregnancy?*
Yes No 

How many babies have you had?

 
Have you ever had a C-section?*
Yes No 

How many C-sections have you had?

 
Any problems with a previous pregancy?*
Yes No 

 
If yes, please provide details below:

 
Do you have any medical issues?*
Yes No 

 
If yes, please provide details below (i.e. diabetes, epilepsy, heart disease)

 
Are you on any medication?*
Yes No 

 
If yes, what medication?

 
Family Doctor`s Name:

Family Doctor`s Address:

  
Midwifery Information
  
Have you had previous midwifery care?*
Yes No 

 
Please provide details of prior midwifery care (ie. where/who, and when):

  
Please list (in order of preference)
any specific midwives you would like to request:

  
Where would you like to deliver?*

  
Who referred you to our care? (i.e. Self, Family Doctor, Obstetrician, Other. Please specify below)*

  
Why are you interested in midwifery care?

  
Do we have your permission to share your name,
postal code, and date of birth with Grand River
Community Health Centre and the Ministry of Health
to help in the collection of statistics about women
who are unable to obtain midwifery services?

If you say no, this will not
affect your access to midwifery care.*
Yes No 

 
The Midwives wish you to be aware that folic acid supplementation of 0.4 to 1mg/day
is recommended for all women before getting pregnant and throughout pregancy.
  
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