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Kensington Midwives - Intake Form
Please complete the intake form below to the best of your ability. If you have any questions or are having difficulty with this form, please call our office at 416-928-9777 to complete the questionnaire over the phone. Once we receive your information we will contact you by email or phone within 2-10 business days.
Do you have a health card? (ie. OHIP, IFH, UHIP, or other provincial health card)
*
please select
Yes
No
Name (as it appears on your health card or other official documents)
*
First
Last
Preferred Name
What pronouns do you prefer? (she/her, he/him, they/them, or other pronouns)
Your Date of Birth
*
MM
/
DD
/
YYYY
Best Contact Number
*
###
-
###
-
####
Can we leave a confidential message at this number?
*
Yes
No
Email
*
Confirm
Name of your partner/support person
First
Last
Your partner/support person's contact number
###
-
###
-
####
Do you give us permission to communicate with your partner/support person about your care (ie appointment times, test results, etc). You can remove this permission at any time.
Yes
No
Street Address
(include apt. & buzzer #)
*
Postal Code
*
Main Intersection
*
Are you planning to move during your pregnancy?
*
No
Yes
If so, to where?
First Day of Last Menstrual Period
*
MM
/
DD
/
YYYY
Are you certain of the date of your last menstrual period?
*
Please select
Yes
No
Do you have a 28 day cycle? (every 28 days)
*
Please select
Yes
No
If not, how many days is it typically?
If known, please enter your estimated due date
MM
/
DD
/
YYYY
Has this due date been confirmed by ultrasound?
Yes
No
Where would you like to give birth? Our midwives can only deliver at St Joseph's, the Toronto Birth Centre, or at home.
*
Please select
Home
St Joseph's Health Centre
Toronto Birth Centre
Unsure
Have you had any previous births?
*
No
Yes - vaginal
Yes - c-section
Yes - both vaginal & c-section
How did you hear about Kensington Midwives?
please select
I am a past client
Kensington Midwives website
Social Media
Ontario Midwives website
through a friend
through a doctor
through another healthcare provider
We invite clients speaking any language to apply for care. If you are not able to communicate in English and would like to request someone who speaks another language as part of your team, please specify below. A place with these midwives is not always possible but ALL of our midwives can provide for you using other interpretive services, and any help you can bring with you will be helpful.
French
Amharic
Please select all that apply.
Additional Comments