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

  • Primary Midwife
    Primary Midwife
    Backup Midwife
  • Waiting List
    Waiting List
    Select "No contact/Not on wait list" if you are not on a waiting list. Otherwise select the practice you contacted.
  • Personal Information

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  • - -
  • - -
  • Select the language that you regularly communicate in.
  • Health Insurance Information

  • About Your Current Pregnancy and Health

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  • / /
  • Vaginal
    C-section
    VBAC
    Only select how many actual number of vaginal, c-sections or VBAC you had. Otherwise select 0
  • Additional Information

  • 1st Choice
    2nd Choice
  • 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: