Intake Form for Madawaska Valley Midwives

Use this tool below to calculate your due date, then enter in the intake form below.

We will respond to you to confirm receipt of your intake form at the email address you provide. If you do not receive that confirmation email in ten business days, please check your spam/junk mail, or follow up at 1-833-687-6333 or info@mvmidwives.ca.

Ideally we would take into care every woman who wanted a midwife. Realistically, we have limitations due to the number of midwives available and the number of births allowed by the MOHLTC.

Our administrator will contact you within ten business days to let you know if we can accommodate you.

Fields marked with an * are required.

* required field:

Name (as it appears on your OHIP/Health card)*

Family name

Given names(s)

Have you been in the care of midwives before?*

Yes No

Are you a repeat client of Madawaska Valley Midwives?*

Yes No

Email address*

Enter your due date here:

/ /

If you cannot provide a due date, please select a reason

Address*

Number and Street

City

Province

Postal code

Are you a resident of Ontario?*

Yes No

Midwifery care in Ontario is free for Ontario residents, whether or not you have an OHIP card.

Are you a Canadian Citizen?*

Yes No

What is your date of birth?*

/ /

Primary phone number?*

Is it okay to leave a message?

Yes No

Alternate phone number?

Alternate phone type?

Is it okay to leave a message?

Yes No

You are welcome to provide us with your pronoun (ex: her/he/they)

When was the first day of your last menstrual period (LMP)

/ /

How long is your menstrual cycle in days? (for example, 28 days between cycles)*

NOTE: Please note that we are unable to process your form without an LMP or a due date.

How many prior pregnancies have you had?*

How many times have you given birth?*

How many vaginal births have you had?*

How many c-sections have you had?*

Do you have any major medical problems like hypertension, diabetes or epilepsy?*

Yes No

If yes, please provide more information about their duration, severity and what treatment (if any) you are receiving:

Did you have any problems with a previous pregnancy or birth?*

Yes No

If yes, please provide more information:

Where do you plan to have your baby?*

Do you have a Family Physician/Nurse Practitioner? Please provide their name and location.

Have you been receiving prenatal care for this pregnancy.*

Yes No

If yes, then please provide the name of your current prenatal care provider.

The Ministry of Health asks us for some information about people seeking midwifery care to track the demand of midwives in the province. May we give your information to the Ministry of Health?*

Yes No

Would you like to share any other information about yourself? (for example, Do you identify as Indigenous or belong to an Indigenous family? Do you identify as being black or a person of colour? Do you identify as LGBTQ+? Are you a surrogate)?

Madawaska Valley Midwives takes your personal information seriously and we have taken measures to protect your privacy.
Despite this, unforseen vulnerabilities can always exist which could compromise the system and the security of your information. Our privacy policy and statement are found in the resources section of our website.

I Understand