COMMUNITY MIDWIVES OF BRANTFORD
Intake Form
About Us
Our Midwives
Birth Stories
Location
Contact
Student Evaluation
What is Midwifery?
Pregnancy
Pregnancy Care for Clients
When to Call your Midwife
Working with Students
Pregnancy Resources
Booklist
Crisis Lines
Birth
Home and Hospital Birth
Midwifery Care During Birth
Preparing for Birth
Postpartum
Care for Clients After Birth
Care for the Newborn
When to Call Your Midwife
Breastfeeding
Leaving Midwifery Care
Midwifery Care Evaluation Form
Intake Form
If you would like to request care from our midwives, please fill out this form in its entirety. Fields indicated by a red star are required. Your request will be sent directly to us and our support staff will contact you if we are able to provide you with care.
If you would prefer to provide your details by phone or are experiencing difficulty with this form please feel free to contact us at: 519-751-6444.
Please calculate your estimated due date
here
before completing the form below.
Name (as it appears on your Health Card)
*
First
Last
Name you would like to use if different from your Health Card
*
First
Last
Maiden Name
*
Do you have a health card (OHIP)?
*
Yes
No
Birthday
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
*
Indicates required field
Phone Number
*
Is it okay to leave messages at this number?
*
Yes
No
Email
*
Address Line 1
*
Address Line 2
*
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
*
Country
*
Partner Name
*
Have you ever been a client of midwifery care?
*
Yes
No
If you have been a client of midwifery care, where/what clinic and who was your midwife?
*
When is your estimated due date?
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Due Date Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Due Date Year
*
2019
2020
2021
Need help
calculating your due date?
When was the first day of your most recent menstrual period (LMP)? Please note that we are unable to process your form without an LMP or due date.
First Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
LMP Month
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
2018
2019
2020
2021
2022
*
Not sure
Do you have a 28 day cycle?
*
Yes
No
If "no," how long is your cycle?
*
*
My cycles are not regular
How many vaginal births have you had?
*
How far along were you in your previous pregnancies when you delivered?
*
How many C-section births have you had?
*
When was your last C-section (month and year)?
*
If you've had a C-section previously, what is your hope/plan for this birth?
*
A vaginal birth
Another C-section
Are you currently taking any medications?
*
Yes
No
If yes, what medications?
*
Do you have any major medical problems like diabetes or epilepsy?
*
Yes
No
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.
*
Did you have any problems with a previous pregnancy or birth?
*
Yes
No
If yes, please provide more information.
*
Do you want a home or hospital birth?
*
Home
Hospital
Undecided
Family Doctor
*
Address
*
City
*
Phone Number
*
How did you hear about Community Midwives of Brantford?
*
Internet Search
Advertisment
Friend
Other
Why are you seeking midwifery care?
*
Anything else you'd like to tell us?
*
The Ministry of Health and Long Term Care asks us for some information about people seeking midwifery care to track the demand for midwives in the province. May we give your information to the Ministry of Health for this purpose? Your information is kept confidential
*
Yes
No
Submit
Intake Form
About Us
Our Midwives
Birth Stories
Location
Contact
Student Evaluation
What is Midwifery?
Pregnancy
Pregnancy Care for Clients
When to Call your Midwife
Working with Students
Pregnancy Resources
Booklist
Crisis Lines
Birth
Home and Hospital Birth
Midwifery Care During Birth
Preparing for Birth
Postpartum
Care for Clients After Birth
Care for the Newborn
When to Call Your Midwife
Breastfeeding
Leaving Midwifery Care
Midwifery Care Evaluation Form