Your Name:

Language spoken at home

Have you had a midwife from our collective in the past? If so, what year:

not applicable20112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980

Name of midwife

Your date of birth

Major street intersection where you live in Toronto

Postal code

Your Phone Number:

Is it okay to leave messages at this number?

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

Alternate phone number

Is it okay to leave messages at this number?

Email address:

Your due date

When was the first day of your most recent menstrual period?

How many vaginal births have you had?

How many C-section births have you had?

Do you have any major medical problems like diabetes or epilepsy?

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?