Book an Appointment

If you are currently pregnant and want care with our Midwifery Practice, complete the form below. You do NOT need a doctor’s referral. We will contact you within 2 business days

Your Full Name *
Your Full Name
Partner's Full Name
Partner's Full Name
Address *
Address
Primary Phone Number *
Primary Phone Number
Partner's Phone Number
Partner's Phone Number
Can we leave you a voice message on these numbers? *
Date of Birth *
Date of Birth
Is this your first pregnancy? *
Have you had a Midwife before?
What was the first day of your last period? *
What was the first day of your last period?
Do you have an Ontario Health Card (OHIP)? *
Do you consent to sharing your information with the Ministry of Health? *