REQUEST A MIDWIFE

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.

Your date of birth:
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)?
Did you use a midwife?
If so, who? (Check all that apply):
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?
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?
How did you hear about us?