Request care

Midwives accept clients at all stages of pregnancy. Vacancies can arise at any time and we try to accommodate all due dates. Do not hesitate to fill out an intake form regardless of your due date, or previous care provider. Once we receive your request, we will call you in the next 7-10 business days.

First and last name (as they appear on your health card)

Preferred Pronouns (Optional)

Your Email

Name of your partner/support person

Address

Unit/Apartment #

Postal code

Do you have OHIP or other health coverage?

If you have an OHIP (Ontario Health Card), please enter the number

Language(s) spoken at home

Phone number (where we can leave messages)

Alternate phone number

Date of Birth

Day

Year

How many days is your cycle?

Is it regular?

First day of your last period

Enter your conception or insemination date if known

Enter your due date if known

Day

Where do you plan to have your baby?

How many times have you been pregnant?

How many losses or terminations have you had?

How many vaginal births have you had?

How many C-section births have you had?

If you have already had a baby, how many weeks pregnant were you when you gave birth?

Do you have any medical conditions like diabetes, epilepsy or thyroid issues?

Have you received any prenatal care for this pregnancy so far?

If you have had a midwife from our clinic before, please tell us who

If you selected Other, please tell us who

If you were referred by someone, please tell us who

Any additional comments?

We treat the information gathered on this intake form with strict confidentiality. However, with your permission, if we don't have room to take you on as a client, we do provide the Ministry of Health with your name, date of birth and postal code as a way of demonstrating the need for more midwives in the province. In turn, the Ministry of Health would only release overall statistics without identifying your information. Do we have your permission to share your information?

Midwife alliance

A client based midwifery practice serving the west end of Toronto

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