May we leave a message on your voicemail or with party who answers? Please comment...
Do you have an Ontario Health Insurance Plan (OHIP)?
If yes, what is your partner's name?
Are you a Repeat
Ontario Midwifery Client?
Optional: Do you consider yourself to be from a marginalized group(s) based on the following:
Teen, Low Income, Immigration Status, Race, Sexuality, Level of Ability, etc.?
If so, please list...
What is the first date of your last menstrual cycle?
What is your expected date of delivery?
How many pregnancies have you had, including this one?
How many Vaginal Births have you had?
How many C-sections have you had?
Do you have any major medical problems, or problems in a previous pregnancy? If so, please list...
List any medications, vitamins and herbal supplements currently taken.
List any surgeries you have had.
Have you had prenatal care for this pregnancy?
Where would you like to deliver your baby?
What is your current weight?
What is your current height?
Anything else about your health history you would like us to know?
How Did You Hear About Us?
For billing purposes we are required to release some statistical information about you and your pregnancy to the Ministry of Health. Your name is not used, however some identifiers like yours postal code, your date of birth, and information about your care with midwives will be shared with the Ministry.
Please check this box if you agree we may forward this information for billing purposes:
Consent for release of information to Ontario Ministry of Health and Long Term Care.
I acknowledge that New Life Midwives will not have a clinical role during my pregnancy until they have offered and I have attended an in person booking appointment confirming my acceptance into care.
Are you a Previous
New Life Midwives Client?
If this is a surrogate pregnancy indicate your transfer date.