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

You will be notified if we can take you into our care by your preferred contact method. You will be placed on our waiting list if we are unavailable to take you at this time and will receive an e-mail if this is the case.

Thank you for contacting us.
 
CONTACT INFORMATION
 
First Name (as it appears on Health Card)*

Last Name (as it appears on Health Card)*

Preferred name

Address*

City*

Postal Code*

Email Address*

Home Phone*

Cell Phone

Work Phone

Preferred Contact Method*

Preferred language

 
MEDICAL INFORMATION
 
Date of Birth (MM/DD/YYYY)*

Health Card Number

Health Card Version Code

First Date of Last Period (MM/DD/YYYY)

If unsure, use your best guess
Estimated Due Date (MM/DD/YYYY)

 
Do you normally have a 28 day cycle?
Yes No 

If no, how many days in your cycle

Is this your first pregnancy?
Yes No 

If no, how many babies have you had?

Have you ever had a C-Section?
Yes No 

If yes, how many C-sections have you had?

 
Any problems with a previous pregnancy?
Yes No 

If yes, please provide details here

 
Do you have any medical problems?
Yes No 

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

 
Are you on any medication?
Yes No 

If yes, please list medication here

 
Family Doctors Name

Family Doctors Address

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

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

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

 
Where are you planning to give birth?

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

 
 
The ministry of health collects statistics about people who are unable to access midwifery services. If applicable, do we have your permission to share your name, postal code, and date of birth with Ottawa Healthcare services and the Ministry of Health to help in the collection of these statistics?
However you answer this question 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 three months prior to becoming pregnant and for the first three months after becoming pregnant.

Midwifery care is funded for all residents on Ontario. By submitting this form you are acknowledging that you are or will be a resident on Ontario at the time of your due date.
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