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