Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone Number *

(###)

###

####

Can we leave you a voicemail at this number? *

Yes

No

I agree to communicate with the midwives via email *

Yes

No

Partner's Name

First Name

Last Name

Partner's Phone Number

(###)

###

####

Do you have an Ontario Health Card? *

Midwifery care is free to residents of Ontario even without OHIP

Yes

No

Not Sure

Family physician / Nurse practitioner

Please write first and last name

First Name

Last Name

Family Physician / Nurse Practitioner's phone number

(###)

###

####

Have you had any prenatal care up to this date? *

Yes

No

First day of your last menstrual period?

Optional

MM

DD

YYYY

Estimated due date?

Optional

MM

DD

YYYY

Have you ever had midwifery care? *

Yes

No

Are you a repeat client of ours? *

Yes

No

Have you ever given birth vaginally?

Yes

No

Have you ever had a cesarean section?

Yes

No

Where are you planning to give birth?

For more information about home birth visit: www.ontariomidwives.ca/home-birth

Ross Memorial Hospital

Home

Not sure

As part of our commitment to equity, we welcome you to self-identify to be prioritized for care (select all that apply).

We thank you for sharing this with us.

Person of colour

Indigenous/Aboriginal

New to Canada

Refugee

No OHIP

LGBTQI or non-binary

Mental health concern(s)

Substance abuse

Teen or young parent

Living with a disability

Single parent

Unstable housing and/or finances

Ontario Works recipient

Children's Aid Society / Foster System involvement

Other identity or circumstances that you are comfortable sharing that you feel would be important for us to know (specify below)