Intake Form

Welcome to Midwifery Care North Don River Valley, and congratulations on your pregnancy!
If you would like to request care with our clinic, please fill in the form below.
If you feel the form is not working for you, we would be happy to take your request by phone instead.
Please call (416) 222-0093 to talk to one of our staff.
For any emergencies please go to the nearest hospital Emergency Room.

Contact Information

Upper case required for postal code

123 555 6666 (no dashes)

123 555 6666 (no dashes)

123 555 6666 (no dashes)

please check your e-mail and try again

Your Birthdate


Pregnancy




Did you have any problems with your previous pregnancies or births? Examples can include high blood pressure, diabetes, need for labour induction, forceps or vacuum delivery, too much bleeding, baby stayed in special care nursery.


What is the due date you were given?

For this pregnancy, what was the first day of your last period ?


General Health Information


Other Information

For the purpose of our waiting list and to provide the Ontario Ministry of Health with the information about the needs of midwifery clients so it can better serve them, in the event that we are not able to offer you care, would you consent to giving your name, date of birth, due date and postal code to the Ministry?

If you are experiencing technical difficulties while completing or submitting this form please call us at 416-222-0093.

If you don’t hear from us within 2 business days please call our office at 416-222-0093