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.
Preferred Contact Number:*
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?*
If no, how many days is your cycle?
Is this your first pregnancy?*
How many babies have you had?
Have you ever had a C-section?*
How many C-sections have you had?
Any problems with a previous pregancy?*
If yes, please provide details below:
Do you have any medical problems?*
If yes, please provide details below (i.e. diabetes, epilepsy, heart disease)
Are you on any medication?*
If yes, what medication?
Family Doctor`s Name:
Family Doctor`s Address:
Have you had previous midwifery care?*
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?*
Joseph Brant Hospital
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 Halton Healthcare
Services 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.*
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.