LOADING...  Please wait.

Apply for Midwifery Care
Choosing a midwife for your pregnancy mean choosing them as your primary care provider for your pregnancy and immediate post partum period (6weeks)

In accordance with the Association of Midwives, Midwifery Collective of Ottawa is funded to provide care to all residents in the Ottawa area catchment area

Please not that once you have requested a midwife has been submitted it will take up to a week before our Clinical Administrator gets back to you. We will use the information below to determine availability and suitability of midwifery care for your pregnancy.

Thank you for your interest in the Midwifery Collective of Ottawa
 
CONTACT INFORMATION
 
Legal Name (As it appears on your formal identification)
First*

Last*

Preferred name

What pronouns do you use (e.g.They/Them, She/Her, He/Him)

 
Home Address
Street Address*

Street Address (Line 2)

City*

Postal Code*

 
Email Address*

 
Mobile Phone Number/Best Contact Number*

Is it ok to leave a message at this number?
Yes
No

Alternate Phone Number

 
Preferred language of Care

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

 
Do You have OHIP? Note: Midwives can care for anyone who lives in Ontario even if you don`t have OHIP
Yes
No
Applying

OHIP Number

Version Code

 
First Date of Last Period (MM/DD/YYYY) If unsure, use your best guess

Estimated Due Date (MM/DD/YYYY)

Is this due date based on an ultrasound?
Yes
No

Where do you plan to give birth?*
Home
Ottawa Birth and Wellness Centre
The Ottawa Hospital-Civic
Unsure

How many times have you been pregnant*

 
How many time have you given birth*

Were any of your babies delivered by cesarean section*
Yes No 

Have you previously had midwifery care?
Yes
No

If yes, please provide details (e.g where, when, and with who)

 
Have you had any complications with a previous pregnancy ? Any complications with your current pregnancy?
 

 
Please list any medication you are currently taking

Do you have any medical concerns that you would like your midwife to be aware of? (Diabetes, blood pressure, physical limitations etc.)
 

Have you been receiving any prenatal care for your pregnancy?
Yes
No

Name of Midwifery Clinic or Family Physician currently supervising your care (type N/A if you do not have a regular care provider

 
Is there anything else you would like to tell us about yourself and your family before you first appointment?

Midwifery Information
 
How did you here about our clinic?
I am a previous client
Friend/Family member
Doctor Referral
Community Referral
Internet Search
Social Media
Other

Would you like to request a specific midwife? Please note that we would do our best to accommodate your request but cannot guarantee your placement with this midwife/team due to availability.

 
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 

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.
We thank you for your time and consideration. We would love to accommodated everyone, however due to limited resources, we cannot guarantee you a spot in our care
 
Reset 
Powered by Elbowspace.com