Midwives Application

Demographics

Legal first name

Legal last name

Preferred name

Personal Pronouns

Applicant's date of birth

Address

Apartment/suite, P.O Box, etc.

City

Province

Postal code

Email

Notifications will be sent to this address

Does not have an email address

Primary phone

Extension

Secondary phone

Extension

Are you covered by OHIP?

Yes

No

I don't know

Ontario Health Card Number (OHIP)

Version Code

I do not have an Ontario Health Card

Applicant's Health Information

Are you on medication?

Yes

No

Do you have any medical complications?

Yes

No

Do you have a Family Doctor?

YesNo

Are your cycles 28 days regular?

Yes

No

What was the first day of your most recent period?

Have you had an ultrasound in this pregnancy?

YesNo

Where are you planning to give birth?

Home

Hospital

Undecided

Other

Is there a midwife you would like involved in your care?

YesNo

Is there anything else you'd like to tell us about your current pregnancy or birth plan?

Previous Birth History

Have you used midwives before?

YesNo

How many times have you been pregnant? (including this pregnancy)

Midwifery Care

Demographics

Applicant's Health Information

Previous Birth History