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Quinte Midwives

Phone: 613-962-3000

Fax: 613-771-0200

Email: quintemidwives@quintemidwives.ca

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- Reaching Your Midwife
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Request for Care

Please Complete Form Below

Someone from our office will contact you by email within two weeks to discuss availability.

You should complete this form as soon as you are aware that you are pregnant. You do not have to wait until blood test confirmation. All fields are required to submit.

Your first and last name as they appear on your health card

Your date of birth

Full address with postal code

Preferred phone number

Can we leave a message?

Alternate phone number

Email we can contact you at

What is the BEST way to reach you during the day, on week days? *

Email

Preferred Phone

Alternate Phone

First day of last menstrual period

Estimated due date

Your age at your Estimated Due Date

Current Medications and Supplements

Family doctor or Nurse Practitioner’s name

Have you ever been diagnosed with any medical conditions? If so, please list conditions

Do you see your family doctor regularly for any other health issues?

Do you have any allergies or sensitivities? If yes, please list:

Have you received any medical care during this pregnancy? (Family Doctor, Nurse Practitioner, Midwife, Obstetrician)

Have you been cared for by an Ontario midwife in THIS pregnancy? *

Yes

No

How many pregnancies have you had, INCLUDING this one?

How many babies have you had?

Have you had any problems with any of your pregnancies?

Have you been a past client of Quinte Midwives and if so, who was your midwife?

Preferred place of birth

Do you have an Ontario Heath Card? (Answering No will not prevent you from receiving care.) *

Yes

No

Do you have another type of health coverge? (e.g. Military or another province) *

Yes

No

What languages do you speak?

Do you need an interpreter to access care? *

Yes

No

Do you have a physical disability requiring accommodation? *

Yes

No

If you answered Yes, please tell us more about your disability and the accommodations you require.

Your Partner's Information (if applicable)

Your partner's first and last name

Your partner's age

Your partner's phone number

Clicking the submit button will clear the page.
This means your form has been sent in.
Responses will come by email within two weeks.

Thanks for submitting!
We will contact you by email within two weeks.

Quinte Midwives

AOM – Association of Ontario Midwives

CAM – Canadian Association of Midwives

CMO – College of Midwives of Ontario

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Request for Care

Please Complete Form Below

Your Partner's Information (if applicable)

Clicking the submit button will clear the page. This means your form has been sent in. Responses will come by email within two weeks.

Clicking the submit button will clear the page.
This means your form has been sent in.
Responses will come by email within two weeks.