Welcome to Lincoln Community Midwives

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.

Name

Your date of birth:

Partner's Name

Phone Number

Phone Type

Landline Mobile

Email

Address

City

Postal Code

OHIP number (10 numbers and 2 letters)

Have you had a baby before?

How many times have you been pregnant?

How many times have you given birth?

How did you give birth (Check all that apply)?

Vaginal Cesarean Section Forceps/Vacuum N/A

Did you use a midwife?

If so, who? (Check all that apply):

Niagara Midwives Lincoln Midwives Other Ontario Midwives Other Midwives

Please name the midwives on your team and/or at your birth:

How long is your menstrual cycle (from the start of one period to the start of the next?

First day of your last normal menstrual period:

Estimated Due Date:

Where do you plan to have your baby?

Have you had problems with a previous pregnancy or birth?

If yes, please explain

Do you have a family doctor?

Family Doctor Name:

Family Doctor Phone:

Do you have any medical concerns that require you to see a medical doctor on a regular basis?

Do you take any prescription medications?

BrieflyElaborate

If you are interested in care please read our current COVID policies, found on our website.

After reading these policies, are you able to comply?

Yes No

After reading this information do you understand that these policies may change as new information is provided?

Yes No

Covid Policy Comments

How did you hear about us?

Lincoln Community Midwives is a group of registered midwives providing primary care. We are fully funded by the Ministry of Health.

Welcome to Lincoln Community Midwives

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