Community Midwives of Halton

Intake Form

Have you been in care with us before? *

If yes, who were your midwives?

Have you had midwifery care with a different practice? If yes, which practice and when?

Requested midwife/midwives

Name as it appears on healthcard / Provide Your Given Name *

Have Health Card? *

Healthcard number with version code *

Our practice provides service to women living in Oakville, Milton, west Mississauga and Burlington.

Address *Street Address 1Street Address 2CityState / ProvincePostal / Zip CodeCountry

Home phone # *

Cell phone #

Work phone #

E-mail *

Your Date of Birth *

Average length of menstrual cycle (typically 28 days) *Enter Numbers between 20 - 45

First day of last period *

Due Date (only if known by ultrasound report) *

Height *

Cm or

Feet and Inches

Pre-pregnancy weight *

KG or

LBS

How many times have you been pregnant? *(gravida)

How many babies have you delivered? *(para)

Have you had any problems with previous pregnancies? Did you have vaginal births? If you have had a c-section, why? Date *

Do you have any medical problems like diabetes, epilepsy or heart disease? *

Do you take any medications? If yes, what?

Name, address and phone # of family doctor *

Are you planning on having your baby at Home or at a Hospital? Please specify a location *

Which location would you like to visit? *

Do you prefer attending that location, even if it means you wont get the midwives you requested? *

Why are you interested in midwifery care?

How did you hear about us?

Are you taking folic acid supplements?

Who have you been seeing for care so far in pregnancy?

Can we have your permission to share your name, postal code, and date of birth with Halton Healthcare Services and the Ministry of Health to facilitate in the collection of statistics about women unable to be accommodated by midwifery services? If you say no, this will not affect your access to care. * Yes No

Are you currently residing in Ontario? Yes No

Apply Here

Intake Form