New Life Midwives Intake Form

New Life Midwives Intake Form

Please fill out your contact, pregnancy, and medical history details and provide your consent.
Preferred Birth Location
Where are you planning to give birth? (PLEASE NOTE: OUR MIDWIVES ONLY ATTEND THE LOCATIONS LISTED BELOW)
Contact Details
Full Name

First Name (on OHIP Card if applicable)Last Name (On OHIP Card if applicable)
Preferred Pronoun
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If you have voicemail can we leave a message?
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you have OHIP card?
OHIP Number
OHIP version code
🌿 Equity & Care Preferences (Optional)

At our practice, we are committed to providing respectful, culturally safe, and person-centered care.Research shows that when care aligns with a client’s cultural background and lived experience, it can improve comfort, trust, and overall outcomes—especially for communities that have historically experienced barriers in healthcare.The following questions are optional and help us better understand your needs and preferences. Your answers will not affect your eligibility for care.
Do you identify as part of an equity-deserving or priority population? (Optional)Select all that apply:

Other
(OPTIONAL) Do you have any preferences for your midwifery care provider? Please note, we will do our best to accommodate preferences where possible. All clients have equal access to midwifery care regardless of their response.

Other
Partner Details
Partner Name

First NameLast Name
Partner's Preferred Pronouns
Pregnancy Details
Estimated Due Date

MonthDayYear
Date
First Date of Last Period

MonthDayYear
Date
Do you have a regular menstrual cycle?

Other
If you've received prenatal care in your pregnancy, please indicate your care provider

Other
Is this a surrogate pregnancy?

Other
Indicate your Transfer Date if this is a surrogate or assisted reproductive pregnancy.

MonthDayYear
Date
How many pregnancies have you had INCLUDING this current pregnancy?
How many living Children do you have?
How many C-sections have you had?
How many vaginal births have you had?
First and Last Name of your Family Doctor (If applicable)
Medical History
Do you have any of the following medical conditions?

Other
How tall are you?
What is your pre-pregnancy weight?
Please list any allergies (medications, foods, latex, etc.)
Provide list any previous or current pregnancy complications that may be relevant to your care.
List any surgeries or hospitalizations
Current medications (including vitamins and supplements)
Anything else you would like to share with the NLM team?
Previous Client
Are you a previous New Life Midwives' client?
Who were your midwives?
Consent to Collect and Use Personal Health Information
Do you give permission for New Life Midwives to contact you at the email address you provided in this form?
Date

MonthDayYear
Date
I acknowledge that New Life Midwives will not have the clinical role during my pregnancy.
Signature (Please sign below to confirm your consent)
Should be Empty:

New Life Midwives Intake Form

Preferred Birth Location

Contact Details

🌿 Equity & Care Preferences (Optional)

Partner Details

Pregnancy Details

Medical History

Previous Client

Consent to Collect and Use Personal Health Information