Intake Form - Womancare Midwives

If you are having an issue completing this application, please contact our office at 519-645-0316. Midwifery care spots are based on an applicant’s due date and the availability of a midwife for that due date.

Our catchment area is the City of London, if you reside outside of London, please also apply to the midwifery practice that serves your area. Applicants who live outside London within a 30 minute radius can be considered for care. You can find your catchment area by clicking here https://www.ontariomidwives.ca/find-midwife.

Applicants who reside outside of 30 minutes from London, should only apply to their own catchment.

First Name

Last Name

Address

City

Province

Postal Code *

Phone *

Is this number for:

Can we leave a voicemail at the phone number listed? *

Email *

We generally contact accepted applicants by email, if you do not wish to be contacted by email please advise. Please ensure [email protected] is added to your safe list

Primary language spoken *

Do you have Ontario Health Insurance (OHIP) coverage? (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? 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?

Please tell us about yourself

Date of Birth *

What was the first day of your last period?

Do you have a regular 28 day cycle? If not, how many days:

(If known) What was the date of conception?

What is your estimated date of delivery? *

Has your delivery date been confirmed by ultrasound?

Your primary care provider/doctor/obstetrician:

Have you received prenatal care from your primary care provider?

Has he/she explained Prenatal Screening to you?

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. Prenatal Screening Ontario

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? *

Do you have any medical conditions or health concerns? *

Please list the conditions:

How many previous births have you had? *

What year was your last birth?

How was your last baby delivered?

Vaginal
C-section
Forceps
Other

Have you ever delivered by C-section? *

If your last birth was a C-Section, are you hoping to have a vaginal birth after C-Section (VBAC)?

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? *

Are you a former client of Womancare?

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 [email protected]

* I consent to provide my information listed above to BORN for the sole purpose of this study *