If you are having an issue completing this application, please contact our office at 519-645-0316 Please enable JavaScript in your browser to complete this form.First NameLast NameAddress *Address Line 1CityState / Province / RegionPostal CodePhone *Is this number for:HomeCellWorkCan we leave a voicemail at the phone number listed? *YesNoEmail *Best way to contact youPhoneEmailPrimary language spoken *Do you have Ontario Health Insurance (OHIP) coverage? (please note that OHIP coverage is not required to access midwifery care in Ontario) *YesNoIf 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. *YesNoWill you require an interpreter for your appointments?YesNo 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:YesNo(If known) What was the date of conception?What is your estimated date of delivery? *Has your delivery date been confirmed by ultrasound?YesNoYour primary care provider/doctor/obstetrician:Have you received prenatal care from your primary care provider?YesNoHas he/she explained Prenatal Screening to you?YesNoPrenatal 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 OntarioAre you planning to complete Prenatal Screening?YesNoUnsureArranged by Family DoctorDo you have diabetes or high blood pressure for which you are taking medications? *YesNoDo you have any medical conditions or health concerns? *YesNoPlease list the conditions:How many previous births have you had? *What year was your last birth?How was your last baby delivered?VaginalC-sectionForcepsOtherHave you ever delivered by C-section? *YesNoIf your last birth was a C-Section, are you hoping to have a vaginal birth after C-Section (VBAC)?YesNoN/AIf 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? *YesNoAre you a former client of Womancare?YesNoif not, which midwifery practice were you with:Why are you choosing midwifery? *Are you hoping for:Home BirthHospital Birth (London Health Sciences Centre only)Not certain at this timeHow did you hear about us?Recommended by former clientRecommended by a health care providerOther practiceMiddlesex London Health UnitInternet SearchSignOtherDo 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 *YesNoSubmit Intake Form
