Intake Form - Forest City Midwifery C.A.R.E.

PLEASE READ BEFORE APPLYING FOR CARE

If you are having an issue completing this application, please contact our office at 519-645-0316. Midwifery care spots are based on an applicant’s due date and the availability of a midwife for that due date. We only contact applicants if we have space for their due date and can accept them into our care. Our current capacity allows us to accommodate between 20 – 35 applicants each month. Due to the level of care and time spent with each client we unfortunately can’t accommodate every application.

Our catchment area is the City of London, if you reside outside of London, please also apply to the midwifery practice that serves your area.
https://www.ontariomidwives.ca/find-midwife.

Before completing this application, please acknowledge that you are aware that Midwives are primary health care providers who provide prenatal, labour, delivery and postpartum care to their clients. A pregnant person can choose to have a midwife or a doctor, not both. As midwives are experts in low-risk pregnancy and birth, midwifery clients will not see a physician for pregnancy related care unless there are concerns or complications. If complications arise, midwives can consult with physicians or, if necessary, transfer a client’s care to a Obstetrician.

Please tell us about yourself

First Name

Last Name

Address

City

Province

Postal Code *

Phone *

Is this number for:

Can we leave a voicemail at the phone number listed? *
Yes
No

Email *

We generally contact accepted applicants by email, if you do not wish to be contacted by email please advise. Please ensure admin@forestcitymidwiferycare.ca is added to your safe list

Primary language spoken *

Do you have Ontario Health Insurance (OHIP) coverage? (please note that OHIP coverage is not required to access midwifery care in Ontario) *
Yes
No

If you don’t have OHIP – are you a resident of Ontario? Please note “resident” does not refer to immigration status or Ontario Health Insurance status; but that the applicant resides at a permanent address in Ontario. *
Yes
No

Will you require an interpreter for your appointments?
Yes
No

Date of Birth *

What was the first day of your last period?

Do you have a regular 28 day cycle? If not, how many days:
Yes
No

(If known) What was the date of conception?

What is your estimated date of delivery? *

Has your delivery date been confirmed by ultrasound?
Yes
No

Your primary care provider/doctor/obstetrician:

Have you received prenatal care from your primary care provider?
Yes
No

Has he/she explained Prenatal Screening to you?
Yes
No

Prenatal Screening is optional for all women and not a consideration in your application. Please note the time-sensitivity of this testing. Should you remain on our waitlist, please contact your health provider for more information. Prenatal Screening Ontario

Are you planning to complete Prenatal Screening?
Yes
No
Unsure
Arranged by Family Doctor

Do you have diabetes or high blood pressure for which you are taking medications? *
Yes
No

Please include further details and medications for any boxes checked above:

How many previous births have you had? *

What year was your last birth?

How was your last baby delivered?
Vaginal
C-section
Forceps
Other

Have you ever delivered by C-section? *
Yes
No

If your last birth was a C-Section, are you hoping to have a vaginal birth after C-Section (VBAC)?
Yes
No
N/A

If so, how many births were by C-section?

Were there any concerns with your pregnancy, labour, birth, postpartum or any other concerns you would like to share with us?

Have you previously had midwifery care? *
Yes
No

Are you a former client of Forest City Midwifery C.A.R.E. (Formerly Womancare Midwives)?
Yes
No

if not, which midwifery practice were you with:

Why are you choosing midwifery? *

Are you hoping for:
Home Birth
Hospital Birth (London Health Sciences Centre only)
Not certain at this time

How did you hear about us?

Do you have any additional comments?

Information in relation to your application:

The Ministry of Health and Long-Term Care – which provides funding for the Ontario Midwifery Program – would like to obtain information on the demand for midwifery services around the province.

To help the Ministry get the information it needs, we have agreed to ask individuals, we are not able to accept into care; due to limited services at our practice group, whether they would be willing to provide some basic personal information and consent to the disclosure of this information that will be collected through the Better Outcomes Registry and Network (BORN), a registry that collects information related to maternal, infant and child health.

BORN will provide de-identified information to the Ministry, in order to properly conduct a study that will assist in future planning for midwifery services across the province. This information is important in understanding the growing need for midwifery services and the need to fund more midwives.

You should know that:
▪ the Ministry will not receive your personal information and will only receive de-identified data;
▪ BORN will receive your personal information, only if you consent to this disclosure;
▪ you are under no obligation to provide this information, and if you do not consent, this will have no effect on your eligibility to receive midwifery care in the future; and
▪ BORN, on behalf of the Ministry is collecting this information solely for the purpose of conducting a study to assess the demand for midwifery services in the province, and will use it for no other purpose.

Please indicate your consent to provide your name, birth date, postal code, and expected date of delivery to the Better Outcome Registry Network (BORN)

If you have any questions or concerns about us collecting or disclosing this information, please contact our office at 519-645-0316 ext 222 or admin@forestcitymidwiferycare.ca.

* I consent to provide my information listed above to BORN for the sole purpose of this study *
Yes
No