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
What language(s) do you speak at home?
Your date of birth (required) Month ---JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day ---1234567891011121314151617181920212223242526272828293031 Year ---2009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970
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 ---20222021 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 ---2022202120202019201820172016201520142013201220112010200920082007
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.
We will review the information you have provided and will be in touch as soon as possible to advise you of our availability or to clarify the details on your intake form. If you have not heard from us after two weeks, please contact our office.