Intake Form

* = required fields

About You

Name: *

Do you have a partner?: Yes No

Partner's name:

Language spoken at home:

Your date of birth: *

Address: *
City: *
Postal code: *

Home Phone Number: *

May we leave a message at this number? Yes No

Work Phone Number:

May we leave a message at this number? Yes No

Cell Phone Number:

May we leave a message at this number? Yes No

Email Address:

Other Details Have you been previously cared for by an Ontario midwife?
How did you hear about us?

Do you maintain a current home address in Ontario? Yes No

Do you have a valid OHIP card?
(this will not affect your ability to access midwifery care) Yes No

Are you an American Citizen or a Non Resident of Canada?
(this will not affect your ability to access midwifery care) Yes No

By clicking submit, you acknowledge that Midwives of Headwater Hills is required to release statistical information about your pregnancy and birth to the Ontario Ministry of Health and Long Term Care for billing purposes. If you have questions about this, please call our office before submitting your intake form.

Intake Form

Have questions about midwifery?

Register for midwifery services

Get in touch with us

View a map
of our service area

Intake Form

Have questions about midwifery?

Register for midwifery services

Get in touch with us

View a mapof our service area

View a map
of our service area