Get Intake Form - Diversity Midwives

Filling out the INTAKE FORM for Diversity Midwives is a crucial step in receiving personalized midwifery care. This guide provides clear instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete your intake form.

1. Click the ‘Get Form’ button to obtain the intake form and open it in your preferred editor.
2. Begin by entering the date of completion, your name (last and first), and your date of birth in the designated fields.
3. Provide your current home address, including postal code and nearest intersection, ensuring all details are accurate.
4. Fill in your contact information: home phone number, cell number, OHIP number, and email address. This information will help the midwifery team contact you directly.
5. If applicable, provide your business number and partner’s name in the appropriate sections.
6. Indicate your residential status and any referral information, noting whether you are a new or previous client.
7. In the clinical information section, provide the date of your last menstrual period (LMP), the length of your cycle, and your due date.
8. Specify your parity (the number of pregnancies carried to a viable gestational age) and gravida (the total number of confirmed pregnancies).
9. Report any issues you might have experienced in previous pregnancies or births, if applicable.
10. Indicate whether you have any major medical issues and describe them in the space provided.
11. Specify your prenatal care for the current pregnancy and planned birthplace. You may choose from home, hospital, or birth center, and should indicate who is providing your care.
12. Select whether you would like an information session or wish to book directly into care. Make your choice by marking the appropriate box.
13. Consent to share your information with the Ministry of Health and Long-Term Care by indicating your choice. Understand that consent is optional.
14. Finally, provide any additional comments or information that may be relevant to your care.
15. Once all sections are completed, ensure to save any changes, download a copy of the form, and consider printing it for your records or sharing it as needed.

Complete your intake form online to take your first step towards receiving midwifery services tailored to your needs.