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Intake Form
INTAKE FORM
About You
Name
Street Address
City
Province
Postal Code
Home Phone Number
Cell Phone Number
Work Phone Number
Email Address
May we leave a message on your voicemail or with party who answers? Please comment...
Your Date of Birth
Do you have an Ontario Health Insurance Plan (OHIP)?
Do you have a partner?
If yes, what is your partner's name?
Primary language 
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...
About Your Health
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?
If yes, with whom?
Where would you like to deliver your baby?
What is your current weight?
lbs
What is your current height?
ft, in
Anything else about your health history you would like us to know?
How Did You Hear About Us?
Referral From:
Other: Please specify
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. 
Acknowledgement
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?
Do you have diabetes
If this is a surrogate pregnancy indicate your transfer date.
YesNo
YesNo
YesNo
Unsure
Unsure
YesNo
Past Client
Live in Neighbourhood
Internet
YesNo
I acknowledgeI do not acknowledge
YesNo
yesno