EmailMeForm
WEM Intake Form
If you are pregnant and are interested in midwifery care, please complete our intake form. Midwifery Services is free for clients who reside (live) in Canada
Midwifery History
Are you a past client of WEM?
*
Yes
No
If yes who was/were your midwives
Primary Midwife
N/A
Ren Barrett
Mary Hunking
Manavi Handa
Elaine Ho
Pam Macinnis
Navjot Lidder
Linda Ngo
Laura Coombs
Ashley Smith
Shâdé Chatrath
Jerrylyn Guevarra
Shezeen Suleman
Heidi Kern
Aoife Chamberlaine
Nicole Bennett
Soheyla Owliaei
Marissa Wade
Unknown/Midwife not listed
Primary Midwife
N/A
Ren Barrett
Mary Hunking
Manavi Handa
Elaine Ho
Pam Macinnis
Navjot Lidder
Linda Ngo
Laura Coombs
Ashley Smith
Shâdé Chatrath
Jerrylyn Guevarra
Shezeen Suleman
Heidi Kern
Aoife Chamberlaine
Nicole Bennett
Soheyla Owliaei
Marissa Wade
Unknown/Midwife not listed
Backup Midwife
N/A
Ren Barrett
Mary Hunking
Manavi Handa
Elaine Ho
Pam Macinnis
Navjot Lidder
Linda Ngo
Laura Coombs
Ashley Smith
Shâdé Chatrath
Jerrylyn Guevarra
Shezeen Suleman
Heidi Kern
Aoife Chamberlaine
Nicole Bennett
Soheyla Owliaei
Marissa Wade
Unknown/Midwife not listed
Have you been put on a waiting list at another midwifery practice ?
*
Waiting List
Please select
No contact/Not on wait list
Yes - Midwifery Care-North Don River Valley
Yes - Kensington Midwives
Yes - Midwife alliance
Yes -Community Midwives of Toronto
Yes - Riverdale Community Midwives
Yes - Diversity Midwives
Yes - Midwifery Care of Peel & Halton Hills
Yes - Other
Waiting List
Please select
No contact/Not on wait list
Yes - Midwifery Care-North Don River Valley
Yes - Kensington Midwives
Yes - Midwife alliance
Yes -Community Midwives of Toronto
Yes - Riverdale Community Midwives
Yes - Diversity Midwives
Yes - Midwifery Care of Peel & Halton Hills
Yes - Other
Select "No contact/Not on wait list" if you are not on a waiting list. Otherwise select the practice you contacted.
If you selected other please type the name of the practice(s).
Have you received any prenatal care from another midwifery practice?
*
Yes
No
If yes which midwifery practice?
Personal Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Major Intersection
*
Email
*
D.O.B
*
DD
/
MM
/
YYYY
Home number
*
###
-
###
-
####
May we leave a message at this number
*
Yes
No
Alternative number
###
-
###
-
####
May we leave a message at this number
Yes
No
Do you have a partner?
Yes
No
Language spoken at home?
*
English
Spanish
French
Mandarin
Punjabi
Hindi
Gujarati
Portuguese
Yoruba
Other
Select the language that you regularly communicate in.
Other language if not listed
Health Insurance Information
Health Card Number (OHIP)
*
Do you have health insurance?
*
OHIP
IFH
Private
Other
None
If you do not have OHIP or health care insurance how many years have you been in Canada?
*
Please select
Less than 3 months
3 months but less than 6 months
6 months but less than 12 months
1 to 5 years
6 to 10 years
More than 10 years
Are you a client of a CHC (Community Health Centre)? If so which one?
*
Please select
No
Acess Aliance
Rexdale
Unison
Black Creek
Other
About Your Current Pregnancy and Health
First day of you last menstral cycle?
*
DD
/
MM
/
YYYY
How many days are your cycles?
Please select
Less than 21
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Greater than 35
Unknown
What is your estimated due date
*
DD
/
MM
/
YYYY
How is your due date calculated?
*
Please select
LMP
Ultrasound
IVF
Other
Unknown
How many pregnancies have you had including this one?
*
Please select
1
2
3
4
5
6
7
8
9
10
More than 10
How many births have you had
*
Vaginal
Please select
0
1
2
3
4
5
5 or more
C-section
Please select
0
1
2
3
4
5
5 or more
VBAC
Please select
0
1
2
3
4
5
5 or more
Only select how many actual number of vaginal, c-sections or VBAC you had. Otherwise select 0
Did you have any problems with any of your pregnancies, births, or postpartum?
*
Yes
No
If yes please describe?
Did you have any medical condition(s) e.g., diabetes, high blood pressure, etc?
*
Yes
No
If yes please describe?
Have you had any type of prenatal testing this pregnancy?
*
None
Pregnancy Test
Prental blood work
Ultrasound
Pap Smear
Genetic Screening/Testing
Glucose (GDM) Testing
Urine (UTI) Testing
STD Testing
Other
Where do you plan to deliver your baby?
*
Hospital (Etobicoke General)
Home
Undecided
Additional Information
Do you have a family doctor or nurse practitioner?
*
Yes
No
What is their Contact information?
Are you requesting a particular midwife (midwives) for your care?
1st Choice
Any Midwife/ N/A
Ren Barrett
Manavi Handa
Elaine Ho
Pam Macinnis
Navjot Lidder
Linda Ngo
Laura Coombs
Ashley Smith
Shâdé Chatrath
Jerrylyn Guevarra
Shezeen Suleman
Heidi Kern
Aoife Chamberlaine
Mary Hunking
Nicole Bennett
Soheyla Owliaei
Marissa Wade
2nd Choice
Any Midwife/ N/A
Ren Barrett
Manavi Handa
Elaine Ho
Pam Macinnis
Navjot Lidder
Linda Ngo
Laura Coombs
Ashley Smith
Shâdé Chatrath
Jerrylyn Guevarra
Shezeen Suleman
Heidi Kern
Aoife Chamberlaine
Mary Hunking
Nicole Bennett
Soheyla Owliaei
Marissa Wade
How did you hear about us?
Consent for release of information to Ontario Ministry of Health and Long Term Care. For billing purposes we are required to release some statistical information about you and your pregnancy to the Ministry of Health. Your name is not used, however some identifiers like yours postal code, your date of birth, and information about your care with midwives will be shared with the Ministry. Please check this box if you agree we may forward this information for billing purposes:
Yes
No