Congratulations on your pregnancy!

Have you been in care with us before? *

If yes, who were your midwives?

Have you had midwifery care with a different practice? If yes, which practice and when?

Requested midwife/midwives

Name as it appears on healthcard *

Healthcard number with version code

Our practice provides service to women living in Oakville, Milton and west Mississauga.

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home phone # *

- Area Code Phone Number

Cell phone #

- Area Code Phone Number

Work phone #

- Area Code Phone Number

E-mail

Your Date of Birth *

Month Day Year

Average length of menstrual cycle (typically 28 days) *

First day of last period *

Due Date (only if known by ultrasound report)

- Month - Day Year

Height *

Type of Height? *

Pre-pregnancy weight *

Pre-pregnancy weight in KG or LBS? *

How many babies have you delivered? *

Have you had any problems with previous pregnancies? Did you have vaginal births? If you have had a c-section, why? Date *

Do you have any medical problems like diabetes, epilepsy or heart disease? *

Do you take any medications? If yes, what?

Name, address and phone # of family doctor

Are you planning on having your baby at Home or at a Hospital? Please specify a location *

Which location would you like to visit? *

Do you prefer attending that location, even if it means you won't get the midwives you requested? *

Why are you interested in midwifery care?

How did you hear about us?

Are you taking folic acid supplements?

Can we have your permission to share your name, postal code, and date of birth with Halton Healthcare Services and the Ministry of Health to facilitate in the collection of statistics about women unable to be accommodated by midwifery services? If you say no, this will not affect your access to care. *

Yes No