Start your pregnancy journey with us. Name as it appears on your health card* * First Name Last Name Preferred pronouns Primary Language Email * Cell Phone (###) ### #### Home Phone (###) ### #### Preferred phone number for us to contact you: Cell Home Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Health Card Number * Health Card Expiration Date MM DD YYYY First day of last menstrual period MM DD YYYY Estimated due date MM DD YYYY Do you have a 28 day menstrual cycle? Yes No If not, how long is your cycle? Name of family doctor or nurse practitioner Is this your first baby? Yes No If no, how many babies have you had? Were they born on, before or after their due date? Before due date After due date On due date If so, by how many days? Do you have a serious medical condition? Please list any medications you are taking Have you ever been a client of Midwives of Muskoka? Yes No If yes, who was your midwife and the year? Have you ever received midwifery care from another practice? Have you considered where you would like to deliver? Home Hospital If Hospital, which one? Have you had a previous c-section?* Yes No If yes, are you planning another c-section? Yes No Unsure Preferred pharmacy Are you taking a prenatal vitamin? Yes No Is there anything else you would like us to know? Thank you for sending in your application for care. Our office will contact you within the next few weeks.
