Intake Form

for Madawaska Valley Midwives

* 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?*
Are you a repeat client of Madawaska Valley Midwives?*
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?*
NOTE: Midwifery care in Ontario is free for Ontario residents, whether or not you have an OHIP card. Non-residents of Ontario can access midwifery care but must pay for this service. Please call us if you would like more information at 613-687-6333 or toll-free at 1-833-687-6333.
Are you a Canadian Citizen?*
What is your date of birth?*
/ /
Primary phone number?*
Is it okay to leave a message?
Alternate phone number?
Alternate phone type?
Is it okay to leave a message?
Any other comments on how to be contacted?
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?*
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?*
If yes, please provide more information:
Where do you plan to have your baby?*
Why are you seeking a midwife?
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?*
Any other information you would like to provide not covered by this form?
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.