To request midwifery care for new or returning clients please fill out this intake form. You may register at any time but we recommend that you contact us as early as possible. By filling out this form you are asking for care from a midwife and agreeing to allow us to collect this information. Any information you provide will be stored in accordance with our privacy policy and the privacy standards for Ontario.

Our intake process includes: reviewing suitability from intake forms and review of availability for the month you are due (spots are limited each month). We will follow up with you via email in 4-6 weeks or by the time you are 12 weeks gestation. Please note we do have two clinic locations and will do our best to accommodate the clinic location that is closest to you, but we can’t guarantee the location.

If you have any questions prior to registering, or concerns about sending personal information online, please call or email us. We will be happy to discuss your questions or take your registration by phone.

Name *

First Name

Last Name

Partner's Name *

First Name

Last Name

Email *

Cell Phone

(###)

###

####

Can we leave a detailed voicemail ?

Yes

Birthdate

YYYY

Address

*If you live in St. Catharines, you must apply for care with Niagara Midwives first

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have OHIP?

Yes

OHIP number (including version code)

Clinical Information

*If you are unsure of your menstrual dates and are new to midwifery care, we do ask that you get a dating ultrasound ordered by either your family doctor or us if you need assistance. If we order an ultrasound for you, it does not guarantee a spot in care will be available to you.

First Day of Your Last Menstrual Period

YYYY

Estimated Due Date

YYYY

Have You Had An Ultrasound For This Pregnancy Yet?

YES

If You Have Not Had An Ultrasound, Are You Interested In A Dating Ultrasound To Determine Your Due Date?

YES

Desired Birth location

Were any of your Babies Delivery by C-Section?

Yes

N/A

Previous Midwifery Client

YES

OTHER MIDWIFERY PRACTICE

How many times have you been pregnant? (Including this time)

How many times have you given birth?

Team Used in Previous Pregnancies

Year

Have you had any complications with a previous pregnancy or the current pregnancy?

example: gestational diabetes, hypertension

Please list any medications you are currently taking

Do you have any medical concerns your midwife should be aware of?

Ex. diabetes

Have you been receiving any prenatal care for your pregnancy?

Yes

Name of physician or midwifery group currently supervising your care

Who is your family doctor?

Is there anything else you wish to tell us about yourself or your family

How did you hear about us?

The Ministry of Health collects statistics about people who are unable to access midwifery services. If applicable, do we have your permission to share your name, postal code, and date of birth with the Ministry of Health to help in the collection of these statistics? However you answer this question will not affect your access to midwifery care*

Yes

Thank you!

Niagara Falls Clinic

5637 Main Street
Niagara Falls, Ontario
L2G 5Z3

Hours

Tuesday — Thursday
9:00am — 5:00pm
Friday
9:00am - 4:00pm

Contact

renaissancemidwives@gmail.com
(905)-353-0852

Welland Clinic

196 E Main Street
Welland, Ontario
L3B 3W8

Hours

Tuesday — Thursday
9:00am — 5:00pm

Friday
9:00am - 2:00pm

Contact

wellandmidwives@gmail.com
(905)-714-7258

We welcome all families.

Our clinics are situated on treaty land that has traditionally been home to the Hatiwendaronk, the Haudenosaunee, and the Anishinaabe peoples, including the Mississaugas of the Credit First Nation.