Congratulations on your pregnancy!

Thank you for your interest in Womancare Midwives. Please complete the application below to tell us more about yourself.

If you are having an issue completing this application, please contact our office at 519-645-0316

Contact Info

First name:
Last name:
Address:
 
City:
Province:
Postal code:
 
Best phone number to reach you:
Is this number for:
Can we leave a voicemail at your phone number listed?
Yes
No
 
Email address:
Primary language spoken:
Do you have Ontario Health Insurance (OHIP) coverage?
Yes
No
(please note that OHIP coverage is not required to access midwifery care in Ontario)
 
If you don’t have OHIP - are you a resident of Ontario?
Yes
No
Please note “resident” does not refer to immigration status or Ontario Health Insurance status; but that the applicant resides at a permanent address in Ontario.
 
Will you require an interpreter for your appointments?
Yes
No

 

Please tell us about yourself

Your date of birth:
What was the first day of your last period?
Do you have a regular 28 day cycle?
Yes
No
If not, how many days:
(If Known) What was the date of your conception?
What is your estimated date of delivery?
Has your delivery date been confirmed by ultrasound?
Yes
No
 
Your primary care provider/doctor/obstetrician:
Have you received prenatal care from your primary care provider?
Yes
No
 
Has he/she explained Prenatal Screening to you?
Yes
No
 
Prenatal Screening is optional for all women and not a consideration in your application. Please note the time sensitivity of this testing. Should you remain on our waitlist, please contact your health provider for more information. http://www.prenatalscreeningontario.ca/
 
Are you planning to complete Prenatal Screening?
Yes
No
Unsure
Arranged By Family Doctor
 
Do you have diabetes or high blood pressure for which you are taking medications?
Yes
No
Do you have any medical conditions or health concerns?
Yes
No
 
Please list conditions or concerns:
 
Number of previous births:
Year of your last birth:
How was your last baby delivered?
Vaginal         C-section         Forceps        
Other    
If your last birth was a C-Section, are you hoping to have a vaginal birth after C-Section (VBAC)?
Yes
No
N/A
 
Have you ever delivered by C-section?
Yes
No
 
If so, how many births were by C-section?
Were there any concerns with your pregnancy, labour, birth, postpartum or any other concerns you would like to share with us?
Have you previously had midwifery care?
Yes
No
 
Are you a former client of Womancare?
Yes
No
 
if not, which midwifery practice were you with:
 
Why are you choosing midwifery?
 
Are you hoping for:
Home Birth
Hospital Birth (London Health Sciences Centre only)
Not Certain at this time
 
How did you hear about us?
 
Do you have any additional comments?
 

Information in relation to your application:

The Ministry of Health and Long-Term Care – which provides funding for the Ontario Midwifery Program – would like to obtain information on the demand for midwifery services around the province.

To help the Ministry get the information it needs, we have agreed to ask individuals, we are not able to accept into care; due to limited services at our practice group, whether they would be willing to provide some basic personal information and consent to the disclosure of this information that will be collected through the Better Outcomes Registry and Network (BORN), a registry that collects information related to maternal, infant and child health.

BORN will provide de-identified information to the Ministry, in order to properly conduct a study that will assist in future planning for midwifery services across the province. This information is important in understanding the growing need for midwifery services and the need to fund more midwives.

You should know that:
▪ the Ministry will not receive your personal information and will only receive de-identified data;
▪ BORN will receive your personal information, only if you consent to this disclosure;
▪ you are under no obligation to provide this information, and if you do not consent, this will have no effect on your eligibility to receive midwifery care in the future; and
▪ BORN, on behalf of the Ministry is collecting this information solely for the purpose of conducting a study to assess the demand for midwifery services in the province, and will use it for no other purpose.

Please indicate your consent to provide your name, birth date, postal code, and expected date of delivery to the Better Outcome Registry Network (BORN)

If you have any questions or concerns about us collecting or disclosing this information, please contact our office at 519-645-0316 ext 222 or admin@midwives.on.ca.

* I consent to provide my information listed above to BORN for the sole purpose of this study
Yes
No
 
Upon submitting this application, you should receive a confirmation email. If you do not receive the confirmation email, your application has not been received. Please resubmit or contact admin@midwives.on.ca. Please ensure you add admin@midwives.on.ca to your contacts list to ensure you receive your confirmation email.
 
 
We thank you for sharing your information with us. We do our best to accommodate all applicants, however due to limited resources; we cannot guarantee a spot in our care. We only contact applicants once a spot has become available. In order to accommodate the demand of applicants seeking midwifery care, we ask if you have been accepted to another practice that you email admin@midwives.on.ca to remove yourself from our wait list
 
 

Contact Us

Womancare Midwives
101-345 Westminster Avenue
London, Ontario
N6C 4V3

Telephone:
519-645-0316

Fax:
519-645-8802

Email:
admin@midwives.on.ca

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