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First name
*
Last name
*
Home phone #
*
or
Cell phone #
*
Email address
*
OHIP?
*
Yes
No
Due date
*
or
Last Menstrual Period
*
Number of pregnancies
Number of children
Your date of birth
*
Partner's name
Planned place of birth
*
-- Please select --
Home
Birth Centre
Hospital
Undecided
No Ontario address
Street and house #
*
City
*
Postal code
*
Current medications
Medical concerns
Preferred midwife
Where did you hear about us?
*
-- Please select --
Facebook
Friend
Birth Centre website
I am a repeat client
Community Health Centre
Family Physician
Nurse Practitioner
Obstetrician
Public Health Nurse
CAS (Children's Aid Society)
Community organization (Canadian Mental Health Association, shelter, etc.)
Online search
Other
please specify
*
Comments
As part of our midwifery practice's commitment to equity, we welcome you to self-identify to be prioritized for care:
Racialized or a person of color
Indigenous/Aboriginal
Newcomer to Canada
Non-OHIP
LGBTQI or gender non-conforming
Mental health concern(s)
Substance use
Living with a disability
Teen or young parent
Planning a vaginal birth after caesarean(s)
Other identity or circumstances that you are comfortable sharing that are important for us to consider (including issues of poverty, violence, etc):
please specify
* We thank you for sharing this with us. We do our best to accommodate everyone, however due to limited resources we cannot guarantee a spot in our care.