familymidwiferycare.ca » Ask for a Midwife

Ask for a Midwife

To request midwifery care, you can call our office or fill out this form online. By filling out this form you are asking for care from a midwife and agreeing to allow us to collect this information. Within approximately one week we will contact you to let you know if we are able to care for you. Any information you provide will be stored in accordance with our privacy policy and the privacy standards for Ontario(privacy code).

Please be aware that we cannot guarantee the security of your private information while it is in transit by email. If you have any concerns about sending personal information via email, please feel free to call our office and talk to us directly.

Your Contact Information

Your first name
Your last name on your health card
Last name you use (if different from health card)
Your Email(valid email required)
Your birthdate
Address
City
Postal Code
Home Phone
Cell Phone
Work phone
Is it ok to leave messages for you at home?
Yes No
Ontario Health Card Number (if you have one)

Pregnancy information

First day of your last menstrual period
Regular cycles?
Yes No
Due date (if you know)
Is someone looking after you for your pregnancy now?
Yes No
Where do you plan to have your baby?
Home Hospital Not sure

Information about other pregnancies

How many times have you been pregnant:
How many times have you given birth:
vaginal births:
cesarean births:
Have you had a midwife before?
Yes No
Are you hoping to have a specific midwife?
Do you have any health problems?
Did you have any problems in another pregnancy or birth?

Partner Info (if applicable)

First Name
Last Name

A bit more info...

How did you hear about us?
Anything else you would like us to know?

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