Register Please complete the following form to the best of your ability and click Submit. Completing all of the fields will reduce processing time for your registration and help you avoid being placed on the waiting list. CONTACT INFORMATIONName: First Last (Last name as shown on Health Card only)Address: Street Address City Postal Code Apartment Number:Buzzer Number:Primary Phone Number:(if we need to re-schedule your appointment) Please advise if your number is long distance.Secondary Phone Number:Email Address: MEDICAL INFORMATIONHeight (in cm only):Weight in kg only (before pregnancy):Full Name & Phone number of Family Physician:Have you ever had a midwife before?YesNoHave you signed up at another midwifery?YesNoHow many times have you been pregnant (including this pregnancy)?How many children do you have?How many home births have you had?How many Caesarian sections have you had?When was the first day of your last menstrual period?eg. Oct. 10, 2018How often do you get your periods?Are your cycles regular?YesNoWhere are you planning to give birth, Hospital, Home or our Birth Suite?How did you hear about KW Midwifery Associates?Do you have any medical conditions including any that occurred during a previous pregnancy? Please be specific as it may impact your ability to receive midwifery care.Are you currently on any prescription medications? Please be specific.YesNoPlease list your current medications:Additional information:Do you have any specific midwife requests?NOTE: The Ministry of Health is collecting data on the demand for midwives. May we have your consent to share your health card number when we receive it? This information will help get more midwives in the area.YesNoDo you have an Ontario Health Card (OHIP)?YesNoIf you do not have an Ontario Health Card, what is your status in Canada? eg. visitor, foreign student, landed immigrant etc. Yes, send me email updates about KWMA events and information. cssadminRegister02.24.2014
