midwivesoflindsay@gmail.com
41 Russell St. West | Lindsay, ON
P: 705-324-4664
F: 705-324-4668

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Intake Form

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If you are interested in midwifery care, we welcome you to fill out this form.

The first step is an initial phone call with a midwife from our team to answer questions, share information and determine if midwifery care is the right choice for you. Once this form is submitted, our administrator will call you within 7 to 14 days. Keeping your personal health information safe is very important to us.

Full Name (as it appears on your health card)
Date Of Birth
YYYY / MM / DD

Street Address
City
Postal Code
Preferred Phone Number
Is it okay to leave voicemail re: your midwifery care on the preferred phone number?

Yes

Alternate Phone Number
Email Address
Do you consent to receiving general midwifery information via email?

Yes

Do you have an Ontario Health Card?
(Midwifery care is free to residents of Ontario even without OHIP)

Yes

Not Sure

Family Physician/Nurse Practitioner
Have you had any prenatal care up to this date?

Yes

If so, with whom?
(First and Last Name, Location & Fax Number)

First day of your last menstrual period (LMP)?
YYYY / MM / DD
What is your estimated due date (EDD)?
YYYY / MM / DD

Have you ever had midwifery care?

Yes

If yes, please indicate location of your midwifery care:
Are you a repeat client of Lindsay Midwives?

Yes

How many times have you given birth?
How many babies were born preterm? (Less than 37+0 WKS)
Have you ever given birth vaginally?

Yes

Have you ever had a cesarean section?

Yes

Where are you planning to give birth?

Ross Memorial Hospital

Home

Not Sure

Please visit this website for more information about home birth: www.ontariomidwives.ca/home-birth

What is your height?
What is your estimated pre-pregnancy weight?
Do you have any of the following health conditions:
type 1/type2 diabetes, serious heart or kidney disease, history of pulmonary embolism?

Yes

Not Sure

Please list your current medications and supplements:
Do you have any medical conditions that you are currently being treated for or in the past?

Do you need more information about midwifery care to make your decision?

Yes

How did you hear about us?
Is there anything else you would like us to know?

Intake Form

Providing Care & Support

Providing Care
& Support