Request A Midwife

Home et|arrow_carrot-2right|9 Request a Midwife

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.

Please note that we require all visitors to the clinic to wear a mask.

"*" indicates required fields

Contact Information

Name (as shown on Health Card):*

Address:*

Date of Birth:*

Ontario Health Card Number:*

Version Code:*

(The two letters that appear after the numbers on your Health Card.)

Primary Phone Number:*

(If we need to re-schedule your appointment.)

This number is long distance to the Kitchener-Waterloo area.

Email Address:*

Partner's Name (if applicable):

Are you an Ontario resident?*

What is your status?*

Please state your status*

Family Doctor Name:

Medical Information

Height:*

Weight:*

lbs

First day of your last period:*

Due date from ultrasound (if known):

How long is your normal menstrual cycle? (ex. 28 days)*

How many times have you been pregnant (including this pregnancy)?*

How many children do you have?*

Have you ever had a home birth*

Have you ever had a Cesarean Section?*

How many Cesarean Sections have you had?*

Please list the dates and reason for having each of your Cesarean Sections?*

Do we have your consent to request your Cesarean Section medical reports?*

Have you had a midwife before?*

Have you received care for this pregnancy at another midwifery practice?*

Are you currently receiving care from an obstetrician for this pregnancy?*

Please list the practice name:*

First Choice for Midwife:*

(Subject to Availability)

Second Choice for Midwife:

Third Choice for Midwife:

Where are you currently planning to give birth?*

Grand River Hospital

KWMA Birth Suite

Home

Are you taking any prescription drugs?*

Please list the name of the medications and why you are taking them:*

Do you have any medical conditions, including mental health conditions?*

Please list the name of the conditions:*

Did you have any medical or mental health issues during your past pregnancies?*

Please list the name of the condition and how it affected your pregnancy:*

The Ontario Ministry of Health is collecting data on the demand for midwives. Do we have your consent to share your health card number with the Ministry of Health when we receive it?*

Are you interested in learning more about the free "Me Breastfeed" Prenatal Workshop and Breastfeeding Buddies resources?

How did you hear about KW Midwifery Associates?

Yes, send me email updates about KWMA events and information.