Apply for Midwifery Care

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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 at least 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
Do you require an interpreter? Yes No
The cost of an interpreter will be covered by the clinic
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 your first appointment?

Midwifery Information
How did you hear 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.

Are you seeking a racialized midwife?
Are you seeking a LGBTQ+ or queer midwife?
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

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