Request for Care

If you are looking for a midwife for your current pregnancy, please fill out the new client intake form below. The information you share will be used to contact you if we can accommodate your estimated due date. Please provide the best number to reach you.
Your first and last name: Preferred Name: E-mail Phone Number Street address and postal code: Emergency Contact and Number Is this your first baby? How many times have you been pregnant including this pregnancy? How many times have you given birth? Number of vaginal deliveries? Number of caesarean deliveries? If you had a caesarean delivery before, do you plan or prefer to have a repeat caesarean section or VBAC/ TOLAC? (Vaginal Birth After Caesarean/ Trial of Labour After Caesarean) What was the first day of your last menstrual period? Estimated due date? Do you have any medical conditions that your physician has stated are high risk? Are you planning a hospital or home delivery? Have you had a midwife before? Any other information you would like to share. Submit