Intake form

First Name (required)

Last Name (required)

Language spoken at home

Have you had a midwife from our collective in the past? YesNo

If yes, what year: (if more than once, give the most recent year)

If you've had a midwife from our collective, please tell us the name:

What pronouns do you prefer for yourself? (him/her/they or another pronoun)

Your date of birth (required)

Major street intersection where you live in Toronto. (We service the area North to HWY 401, East to Woodbine Avenue, South to Lake Ontario, and West to Royal York Road) (required)

Postal code

Please enter your phone number (required)

Is it okay to leave messages? (required)
YesNo

Alternate phone number

Is it okay to leave messages at this number?
YesNo

We have new midwives join our team every year. Are you open to meeting one of these midwives?
yesno

Are you comfortable having a midwife with a student involved in your care?
yesno

If you answered "no" to both having a new midwife and having a student then it is unlikely that we will have a midwife available for you as we are a very active teaching practice and all of our experienced midwives work with students.

Your Email

When is your estimated due date? (required) - Need help calculating your due date?

Unable to estimate your due date to the nearest month

When was the first day of your most recent menstrual period (LMP)? Please note that we are unable to process your form without an LMP or due date.

Not sure about your last menstrual period

How long is your menstrual cycle?

My cycles are not regular

How many vaginal births have you had? (required)

How many C-section births have you had? (required)

Do you have any major medical problems like diabetes or epilepsy? (required)
YesNo
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? (required)
YesNo
If yes, please provide more information

Where do you plan to have your baby? (required)

Do you have plans for pain medication during your labour?

Why are you seeking a midwife?

How did you hear about our clinic?

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

We'll contact you at the email address you've provided above to let you know that we have received your intake form. If you do not receive that confirmation email in the next 2 business days, please check your SPAM/ junk mail or follow up at 416-963-8842 midwivescollective@gmail.com