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 need to make corrections to your intake form after it’s been submitted, please let us know 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.

Ontario midwives are unable to practice outside of the province. If you are a resident of another province, please visit https://havingababy.co/find-a-healthcare-provider to help find a care provider near you.

Fields marked with an * are required.

* required field:

DEMOGRAPHIC INFORMATION

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

Family name

Given name(s)

Preferred Pronouns*

Height*

Pre-pregnancy weight*

kgs

Email address*

Address*

Number & 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 OK to leave a message?

Yes No

Alternate phone number?

Alternate phone type?

Is it okay to leave a message?

Yes No

Have you been in the care of midwives before?*

Yes No

Are you a repeat client of Madawaska Valley Midwives?*

Yes No

PREGNANCY INFORMATION

Enter your due date here:

/ /

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

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.

Do you have a Family Physician/Nurse Practitioner?*

Yes No

If yes, 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.*

Have you had any medical issues this pregnancy so far?*

Yes No

If yes, please provide more information:

MEDICAL HISTORY

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?*

Are you planning a VBAC?*

Yes No Not Applicable

Have you had any abdominal or uterine surgeries (not including c-sections)?*

Yes No

Do you have any of the following:*

Diabetes

Epilepsy / history of seizures

High blood pressure

Heart disease or stroke

None of the above

Are you currently taking any medications other than prenatal vitamins or supplements*

Yes No

Do you have any conditions that require you to see a specialist? (e.g. rheumatologist, neurologist, etc)*

Yes No

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?*

As part of Madawaska Valley Midwives’ commitment to equity, we welcome you to self-identify check all that apply:

Racialized or person of colour

Indigenous / First Nations/ Metis/ Inuit

Newcomer to Canada

Refugee

LGBTQIA+ or non-binary

Teen or young parent

Living with a disability

Unstable housing and/or finances

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

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