Midwives of Georgian Bay
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?
Alternate phone number
Is it okay to leave messages at this alternate number?
How would you like us to contact you to set up an initial appointment?
Is this your first baby? (required)
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?
—Please choose an option—research (AOM, phone book, internet etc.hospitalfamily doctorfriend/relativeother
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) —Please choose an option—homeWPSHCOtherUncertain
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?
