Intake Form

Name (required)

Date of birth - day/month/year (required)

Email

Name of town/area where you live: (required)

Postcal code: (required)

Please enter your main phone number (required)

Is it okay to leave messages at your main number? (required)
YesNo

Please enter your work phone number

Is it okay to leave messages at your work number?
YesNo

Alternate phone number

Is it okay to leave messages at this alternate number?
YesNo

How would you like us to contact you to set up an initial appointment?

Is this your first baby? (required)
YesNo

If no, how many babies have you had? (required)

Have you previously been cared for by an Ontario midwife in the past?
YesNo

If yes, please tell us the midwife's name or practice:

How did you find out about Midwives of Georgian Bay?

When was the first day of your most recent menstrual period?

Not sure about when your last menstrual period was

Do you know when your baby is due? (required) - Need help calculating your due date?

Unable to estimate your due date to the nearest month

Have you received any prenatal care for this pregnancy? (required)
YesNo
If yes, please tell us the physician/midwife's name:

Phone:

Where do you plan to have your baby? (required)

The Ministry of Health 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?
YesNo