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 care at our practice before?
Leave blank if this is your first pregnancy
Leave blank if this is your first pregnancy
Leave blank if this is your first pregnancy
What was the first day of your last period? *
What was the first day of your last period?
If you know your due date, please enter it here
If you know your due date, please enter it here
Do you have an Ontario Health Card (OHIP)? *
Do you consent to sharing your information with the Ministry of Health? *