Request A Midwife — West End Midwives

Your first step to great pregnancy care.

If you are pregnant and are interested in midwifery care, please complete our intake form. A WEM administrative staff will get back to you within 7-10 business days to let you know if we have a midwife available for your due date.

Please complete the form below

Name

First Name

Last Name

What Pronouns Do You Use To Identify Yourself? (Her/Him/They/Or Other Pronouns)

Date of Birth

YYYY

OHIP

Midwives can care for anyone that lives in Ontario regardless of immigration or health insurance status. If you do not have Ontario health insurance (OHIP), don’t worry - a member of our intake team will call you within 7-10 business days.

Yes

Email Address

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Major Intersection

Partner Name

First Name

Last Name

Partner Phone Number

(###)

###

####

Emergency Contact Name

If different from partner.

First Name

Last Name

Emergency Contact Phone Number

If different from partner.

(###)

###

####

When Was The First Day Of Your Most Recent Menstrual Period?

YYYY

Estimated Due Date

https://www.pregnancyinfo.ca/your-pregnancy/healthy-pregnancy/due-date-calculator/

YYYY

Number of Previous Vaginal Births

Number of Previous C-Sections

Have You Had An Ultrasound In This Pregnancy?

Have You Had Any Complications In This Pregnancy?

If yes, explain

Have You Had Any Complications in Previous Pregnancies?

If yes, explain

Do You Have Current Medical Conditions?

If yes, explain

Are You Currently Taking Any Medications?

If yes, please list which medication(s)

Have You Had A Baby With West End Midwives Before?

Yes

Preferred Choice of Birth Place

Requested Midwife