Community Midwives of Halton

If your address changes at any point during your pregnancy or postpartum period, CMOH may decline home visits. If this is the case, all home visits will be scheduled in the office. * I Agree

Health Card

Due Date

How did you come to this date * Menstrual cycle Dating Ultrasound (7-12 weeks) IVF Pregnancy Conception Health Care Provider App or website

Please confirm by using this trusted webpage: https://perinatology.com/calculators/Due-Date.htm

Physician

Fertility Clinic Walk in Clinic Have not seen any care provider

Full Name of Doctor *

Name of Medical Office *

Street Address of Medical Office *

Postal Code *

Phone Number *

Fax Number *

Preferred Pharmacy Location

Previous Pregnancies

No. of Pregnancies Before *

How many babies have you delivered? *

Have you had any problems with previous pregnancies? * Yes No

Have you ever been told you are "High Risk" during pregnancy *

Do you have any medical conditions? Please check all that may apply. * None Diabetes Epilepsy Heart Disease High Blood Pressure Lupus & Autoimmune Disorder

Birth Selections

Community Midwives of Halton adheres to a strict policy against any forms of discrimination or harassment. We do not discriminate based on race, gender, age, religion, disability, sexual orientation or any other protected characteristic. Any form of harassment or discrimination will not be tolerated.

Community Midwives of Halton have privileges at Oakville Trafalgar Hospital and Milton District Hospital. *

At CMOH, we strive to accommodate requests for midwives, clinic locations and hospital preference. That being said, this is not always possible. We will inform you of options available prior to confirming your spot with us so you may make an informed decision. *

If you are accepted and placed with a team, please note that team change requests will not be accommodated. *

Reason for filling out this application on behalf of the pregnant person? *

Your Full Legal Name *

Your relationship to the pregnant person *

Thank you for Applying for midwifery care!

We will review your application and be in touch via e-mail typically within 2 weeks. WE WILL ONLY ACCEPT CLIENTS THAT LIVE WITHIN OUR CATCHMENT AREA. Unfortunately, we cannot accommodate everyone who applies and there is a chance you may be placed on a waitlist. Please continue to see your family doctor or health practitioner for your routine prenatal care, referrals, and/or concerns until you have been seen for your initial visit.

We treat the information gathered on this Intake Form with strict confidentiality. Please note: If we are unable to accommodate you, we will be sharing your name, date of birth and postal code with the Ministry of Health. This information is shared to demonstrate the need for more midwives in our community. *

Apply Here

Intake Form

Pregnant Person

Catchment