New client intake form Legal name First name Last name Address Street City Postal code Phone number Can we leave a voice mail at this number?* Yes No Alternate phone number Can we leave a voice mail at this number?* Yes No Email Date of birth Do you have an Ontario Health Card? Yes No OHIP Number with Version Code First day of last period Estimated due date How many times have you been pregnant (including this pregnancy) How many times have you given birth? Ages of your children Did you have any C-Section? Yes No If yes, in what years? Your height Your weight lbs kg Do you have any medical concerns that your midwife should be aware of? Yes No If yes, provide details Are you currently taking any medication? Yes No If yes, please list the medication you are currently taking Have you received any prenatal care for this pregnancy? Yes No Name of the care provider Considering birth at Home Winchester Hospital (Winchester and Embrun clients only) Cornwall Community Hospital (Cornwall clients only) Undecided How did you hear about our clinic? Previous Client Friend Doctor referral Internet Social Media Other Who was your midwife? The ministry of health collects statistics about people who are unable to access midwifery services. If applicable, do we have your permission to share your name, postal code, and date of birth with Ottawa Healthcare services and the Ministry of Health to help in the collection of these statistics? * Yes No Submit
