Request for Care

Please fill below

Someone from our office will contact you by email within a week to discuss availability.

You should complete this form as soon as you are aware that you are pregnant. You do not have to wait until blood test confirmation. All fields are required to submit.

First and last name as appears on health card

Partner's first and last name

Your date of birth

Full address with postal code

Preferred phone number

Alternate phone number

What is the BEST way to reach you during the day, on week days?

Preferred Phone

Alternate Phone

First day of last menstrual period

Estimated due date

Current Medications and Supplements

Do you see your family doctor regularly for any health issues? Have you ever been diagnosed with any medical conditions? If so, which conditions?

How many pregnancies have you had, INCLUDING this one?

How many babies have you had?

Have you had any problems with any of your pregnancies?

Have you received any prenatal care during this pregnancy?

Family doctor or Nurse Practitioner’s name

Have you been cared for by an Ontario midwife in THIS pregnancy?

Yes

Have you been a past client of Quinte Midwives and if so, who was your midwife?

Do you have an Ontario Heath Card?

Yes

Do you have another type of health coverge? (e.g. Military or another province)

Yes

Thanks for submitting! We will contact you by email within a week.