Intake form

First Name (required - as it appears on your health card)

Last Name (required - as it appears on your health card)

Preferred first name (if different)

Gender

Preferred pronouns (she/her, he/him, they/them, other)

Name of your partner/support person (first and last name)

Address (required)

What city do you live in? (required) ---MississaugaEtobicokeMiltonCity not listed

Major street intersection near your home (required)

Postal code (required)

Your Email

Please review our Email Consent Policy
Do you wish to communicate with our clinic via email (required)
---Yes, I have read and fully understand the Email Consent Policy and wish to communicate with Midwives of Mississauga through emailI would prefer NOT to communicate with Midwives of Mississauga via email

Please enter the best phone number to reach you at (required)

Is this number your:
cellhomepartner's numberother

Is it okay to leave messages? (required)
YesNo

Alternate phone number

Is it okay to leave messages at this number?
YesNo

Is this number your:
cellhomepartner's numberother

What language(s) do you speak at home?

Your date of birth (required)
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031
Year ---20052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968

When was the first day of your last menstrual period? Please note that we are unable to process your form without a sense of when you are due.
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031
Year ---20202019
Not sure about when your last menstrual period was

How long is your cycle, counting from day 1 of one period (ie: Jan 1) to day 1 of the next (ie: Feb 2) : Jan 1 - Feb 2 = 32 days

If you know your estimated due date, enter it here. (required) - Need help calculating your due date? - (not available on mobile browsers)
Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Day ---1234567891011121314151617181920212223242526272828293031

Unable to estimate your due date to the nearest month

Is this based on:
---last menstrual periodultrasoundconception dateother

Where would you prefer to give birth? (required)
---homehospitalundecided

Have you been pregnant before (not counting this pregnancy)? (required)
YesNo

Have you given birth before? (required)
YesNo

How many living children do you have?

How many weeks pregnant were you when you gave birth?

How many vaginal births have you had? (required)
---012345678+

Were forceps or vacuum used for any of your births? (required)
---forcepsvacuumneithernot applicable

How many C-section births have you had? (required)
---012345

If so, what was the reason for C-section

What was the date (month and year) of your last C-section?

Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Year ---201820172016201520142013201220112010200920082007

Did you have any problems with a previous pregnancy, such as high blood pressure, premature labour etc.? (required)
YesNo
If yes, please provide more information

Did you have any problems with a previous birth? (required)
YesNo
If yes, please provide more information

Do you have any medical problems that you see a doctor for on a regular basis? (required)
YesNo
If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving.

Have you received any prenatal care for this pregnancy? (required)
YesNo
If yes, with whom?
---family doctorOB/GYNother midwifeother

Have you had midwifery care previously?
NoYes, at this clinicYes, at another practice in OntarioYes, with a midwife outside of Ontario

Do you have access to OHIP coverage? (please note that OHIP coverage is not necessary to access midwifery care in Ontario)
YesNoUnsure

Is there anything else you would like the midwives to know at this time?

How did you find us?
---selffamily doctorOB/GYNwebsitehospitalfacebookother

We treat the information gathered on this Intake Form with strict confidentiality. Please note: If we are unable to accommodate you, we will be sharing your name, date of birth and postal code with the Ministry of Health. This information is shared to demonstrate the need for more midwives in our community. Please notify us in writing if you do not want us to share this information.

You will receive a confirmation email to let you know that we have received your intake form. Please check your spam filters if you don't receive this form. We will call or email you in the next 3-4 business days. If you don't hear from us or think your form has not been received, please call us to follow up.