Intake Form

Please fill out the requested information (below) for midwifery care by Lincoln Community Midwives.

You should receive an e-mail from our office administrator the next business day confirming receipt of your intake sheet.                         If you do not get a confirmation e-mail, please call our office at 289-566-9350 to follow up.

Date today: (Month XX, 20XX) (required)
Your Full Name (as listed on Health Card): (required)
Your Date of Birth: (Month XX, YEAR)(required)
Your Partner's Name:
Your Email Address: (required)
Your Phone Number: (required)
Your Address:
City: (required)
Postal Code: (required)
OHIP number (10 numbers and 2 letters):
Have you had a baby before? YesNo
How many times have you been pregnant:
How many times have you given birth:
How did you give birth (Check all that apply): VaginalCesarean sectionForceps/Vacuum
Did you use a midwife? YesNo
If so, who? (Check all that apply): Niagara MidwivesLincoln MidwivesOther Ontario MidwivesOther Midwives
Please name the midwives on your team and/or at your birth:
First day of your last normal menstrual period: (Month XX, 20XX)
How long is your menstrual cycle (from the start of one period to the start of the next):
Estimated Due Date: (Month XX, 20XX)
Where do you plan to have your baby?
Have you had problems with a previous pregnancy or birth? YesNo
If yes, explain:
Do you have a family doctor? YesNo
Doctor Name:
Doctor Phone Number:
Do you have any medical concerns that require you to see a medical doctor on a regular basis? YesNo
Do you take any prescription medications? YesNo
If you answered yes to either, please briefly elaborate (all responses are confidential):
Please tell us what appeals to you about midwifery care and any questions you may have for the midwives?
How did you hear about us?
 
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