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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*
Choose a Preferred Contact Method
Home Phone
Cell Phone
Work Phone
Email
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?
Choose Where would you like to give birth?
Home
Ottawa Hospital Civic campus
Ottawa Birth and Wellness Centre
Undecided at this time
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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